Chapter 23, Health Records and Health Information Management & HIPAA

Health Information Management
Health Records
Permanent or long-lasting documentation of all patient care information that applies to individual patients.
Prospective Payment System
System for Medicare patients by which a predetermined level of reimbursement is established before the services are provided. Based on Geographic and demographic data.
Ambulatory Patient Classifications (OUTpt setting)
Classification system of patients based on the International Classification of Diseases, 9th edition, Clinical Modification codes for diagnoses, current procedural terminology evaluation and management codes, and procedure codes, age, sex, and visit disposition; used for reimbursement for health care provided in the hospital outpatient setting.
Diagnosis Related Groups (INpt setting)
System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay (reimbursement based on diagnosis groups and statistics. in the US for physician reimbursement)
Medical Severity for Diagnostic Related Groups
International Classification of Diseases, 9th Edition, Clinical Modification. Universal statistical classification system used throughout the U.S. and the world for coding and reporting diagnoses and procedures. it uses a computer program called grouper for BILLING.
Radiologic codes between 70010 to 79999 (ex. Chest x-ray= 71010).
Health Information Management Practitioners
Term used to encompass both registered health information administrators and registered health information techniques as individuals with either of these credentials who hold a variety of positions within the health information management profession.
Registered Health Information Technicians.
Professionals who are technical experts in health data collection, analysis, monitoring, maintenance, and reporting activities in accordance with established data-quality principles, legal and regulatory standards, and professional best practice guidelines.
Registered Health Information Administrators.
Professionals who posses the expertise to develop, implement, and/or manage individual aggregate, and public health care data in support of patient safety and privacy, as well as the confidentiality and security of health information.
Agencies that set the STANDARDS for maintenance and the adequacy of Health Records.
The Joint Commission on the Accreditation of Healthcare Organizations (formerly TJC).
Organization that accredits hospitals and other health care institutions in the United States.
Healthcare Facilities Accreditation Program.
Accreditation program of the American Osteopathic Association that accredits health care facilities in the United States.
Health Records Content
1. Patient ID
2. Medical History
3. Examination findings
4. Diagnostic and therapeutic orders
5. Clinical observation (with results of therapy)
6.Diagnostic and therapeutic procedures with results
7. Informed consent
8. Conclusion at termination of hospitalization
Electronic Health Record (formerly EMR).
Generally considered as the portal through which clinicians access a patient’s health record, order treatments or therapy, and document care delivered to patients; allows providers to gather multiple types of data about a patient (clinical, financial, administrative, and research.)
Documenting in the patient’s record
Request of service ordered by a identifiable physician (qualified physician’s assistant, qualified nurse practitioner) always accompanied with a diagnosis or sign or symptom.
“No order, no procedure!”
Radiology report
Document that describes the radiograph with the implications of what is seen, wrote or dictated, and authenticated (usually electronically signed) by a physician (radiologist) with the results of the procedure. Included in the patient record.
Current Procedural Terminology, 4th Edition.
Comprehensive listing of medical terms and codes for the uniform designation of diagnostic and therapeutic PROCEDURES; used in the U.S. for coding for physician reimbursement.
Radiologic codes between 70010 to 79999 (Chest x-ray: 71010).
Principle of Health Records documentation
“Not documented, not done!”
Advance Beneficiary Notice
Notice given to a patient, held liable for costs, when Medicare does not cover the procedure (ex. when no Appropriate Indication, medical necessity/symptoms, is present)
Index of Radiologic Diagnoses
(ACR classification for radiologic specimens)
Requirements of Health Records Entries
TJC requires:
1. All HR entries be dated and authenticated and authors identified
2. All written entries in INK
3. Use only medical staff approved abbreviations
4. Timely fashion
Performance Improvement
Process by which the quality of the care and services provided to patients within a health care facility is monitored and evaluated.
TJC 10-steps
1) Assign responsibility
2) Delineate the scope of care
3) Identify Important Aspects
4) Identify Indicators
5) Establish a means
6) Collect & Organize Data
7) Initiate Evaluation
8) Take Actions to Improve
9) Assess Effectiveness
10) Communicate results
TJC Dimensions of Performance
1. Efficacy
2. appropriateness
3. Availability
4. Timeless
5. Effectiveness
6. Continuity
7. Safety
8. Efficiency
9. Respect and Caring
Health Insurance Portability and Accountability Act of 1996.
Federal legislation passed to improve the efficiency and effectiveness of the health care system; components that affect health information include privacy, security, and the establishment of standards and requirements for the electronic transmission of certain health information.
Intents of HIPAA
1. make the management of Health Information easier
2. protect the PRIVACY of patient’s Health Information
3. protect the SECURITY of patient’s Health Information
4. help people OBTAIN/MAINTAIN Health Insurance benefits when they change jobs

More in general:
1) Protect patient information
2) Limit use of patient information
3) Penalize those who misuse information

Protected Health Information
Individual identifiable health information in any form or media. Information related to any healthcare provided to a person. It includes demographic information that can be used to identify the patient. That information can be used in some manner to identify the person.
Examples of PHI: 1) Lab reports; 2); X-Ray 3); Billing Systems; 4) Nursing notes; 5) Phone calls; 6) Conversations about patients.
Consequences of failure to comply with HIPAA rules
1. may be responsible for civil penalties and fines.
(If you do not comply with policies concerning patient privacy:
It may cost you up to $250,000 or result in a 10 year jail sentence.
If you knowingly release patient information:
you may spend 1 year in jail, or pay a $50,000 fine.
If you gain access to health information under false pretenses:
5 year sentence or pay a $100,000 fine)

2. may be accused of criminal violations and can result in even larger penalties and fines and possible jail time.
3. may be excluded from participation in Medicare program.
4. may hurt reputation of hospital.

A document stating the privacy policies and procedures of a covered entity (CE). It is a document that tells patients how their PHI may be used by the Hospital and explains their rights.
This is a form signed by the patient for the use and disclosure of specific PHI. Authorizations should be obtained for uses and disclosures for treatment, payment, healthcare operations, and more.
P.S.: A facility may not condition treatment on receipt of a valid authorization, except for participation in research studies.
Situations when an authorization is NOT required:
– Coroner may have report when patient’s dead;
– Patient is suspected victim of a crime;
– Upon court order;
– on Police request regarding criminal investigation;
– When caregiver suspects child abuse and reports it to police;
– FDA requires report about medical devices;
– Communicable diseases must be reported to state health agencies (who, w/ID, has been infected and what was contracted)
Fees to obtain a copy of your personal medical records:
It is NOT free.
Short records of 15 pages = $ 2 – $55
Long records of 500 pages= $15 – $585

Get access to
knowledge base

MOney Back
No Hidden
Knowledge base
Become a Member