INTERNATIONAL FEDERATION OF HEALTH RECORDS ORGANIZATIONS (IFHRO)

Education Module for Health Record Practice

UNIT 2 - PATIENT IDENTIFICATION, REGISTRATION AND THE MASTER PATIENT INDEX

This unit is designed to enable the participant to discuss methods of patient identification and registration and identify processes required to develop, use and maintain an effective patient identification system in a hospital, clinic or primary health care centre.

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OBJECTIVES:

At the conclusion of this unit the participant should be able to:

1. Discuss the importance of complete and accurate patient identification

2. State the purpose of a master patient index (MPI)

3. List the items, which should be included in a master patient index

4. Develop and implement a master patient index (MPI)

5. Trace the flow of a patient's index card from admission to discharge

6. Use alphabetical or phonetic filing rules to correctly file cards in a manual master patient index

7. Discuss the need for cross‑referencing names in a master patient index

8. State the types of supplies and equipment commonly used for maintenance of a manual master patient index (MPI).

 

A. PATIENT IDENTIFICATION

The identifying information is an important part of a patient's health record. It should include enough information to uniquely identify an individual patient. Most facilities will ask to view and/or copy the patient’s driver’s license or identification card in order to verify this data.

The patient identification data that is collected during the patient registration process is used to populate the Master Patient Index (MPI), which will be discussed later in this unit. The patient identification data may be entered into a computerized database, or manually typed onto a registration form.

This section of the medical record should contain at least the following information:

1. The full legal name of the patient, including the surname (or family name), first name, middle name or initial, suffixes (e.g., Jr.) and prefixes (e.g., Doctor). It is also important to collect the patient’s alias, previous name, or maiden name, as the patient may have been seen at the facility under another name.

2. Internal identification number or hospital registration number. This is the number used to identify and file a health record, also called the patient’s health record number. (This number is may be assigned at the patient’s first inpatient admission or outpatient encounter at this facility, or a new number is also assigned for each subsequent visit.)

3. Place and date of birth (MM/DD/YYYY or DD/MM/YYYY), gender, race, ethnicity, marital status, address, phone numbers, and any unique identifying number, such as a national identification number or social security number.

4. Name, address and telephone number of nearest relative (next of kin) or friend.

5. Name and address of attending doctor, and name and address of referring doctor, if applicable.

6. Occupation, name and address of patient's employer.

7. Date and time of admission or encounter, and name of unit or clinic.

8. Details of health insurance and medico‑legal information if appropriate.

The above information should be obtained from the patient, if possible, or otherwise from the person accompanying the patient to the hospital or clinic.

Care must be taken to ensure the correct spelling of names and that all names are recorded accurately and in full. Patients should be asked how they spell their names (both surname and given names) as names that sound alike may be spelled quite differently. Names should be recorded in the manner used for all official documents of the state or country.

 

B. PATIENT REGISTRATION

The complete and accurate collection of patient identification information is an important part of the patient registration process. For statistical purposes, a method for counting all outpatient encounters and hospital admissions each day is essential. There are a variety of methods in use, which are separate from the allocation of new health record numbers and will be discussed in Unit 7.

Important aspects of patient registration are:

1. When a patient presents at a hospital or clinic for the first time, they should be registered as a new patient. However, to make sure that the patient is, in fact, a new patient they should be asked if they have been to the hospital or clinic previously. Even if they say no, the admission or clinic staff should still check in the facility’s computerized patient database, the manual master patient index or with the health record department, depending upon the level of computerization at the facility. This step is necessary to make sure that the patient does not already have a health record number at that hospital or clinic; and to ensure that duplicate records are not created.

2. If the patient does not have an entry in the MPI or a health record number, the identifying information is collected and either entered into the computerized database, or recorded on the front sheet of a new record. The patient is registered and a patient identification number is assigned. In most hospitals and health care centres, this registration number is used as the patient’s health record number. In a manual system, an Admission, or Patient Register is maintained at the point where the number is issued, and should contain the following information:

Health Record Patient's Name Date of Issue Doctor/

Number Clinic

10 26 42 John Doe 01/01/2004 Dr. Lee

This register is maintained as a control to avoid duplication of numbers and the issuing of the same number to two people.

3. If the patient has an existing file in the MPI and a health record number, the current identifying information should be checked with previous data and changes noted.

 

C. MASTER PATIENT INDEX (MPI)

Indexes are a must for any hospital, health clinic, or primary health care facility. They serve as a guide to the location of an item. An index can be a table, file, or catalogue, listing an item and furnishing information for easy access to that item.

The Master Patient Index (MPI) is a permanent listing, containing the names of all patients who have ever been admitted to or treated in a hospital or clinic (also called Patients' Index, Master Person Index, Patient’s Master Index, or Master File). Because the Master Patient Index is the key to locating a patient's health record, it is considered to be one of the most important tools maintained in the health record department, clinic or primary health care centre. Since health records are filed numerically in most healthcare facilities, the MPI is used to identify a patient’s health record number and locate the record.

Typically, a manual MPI is maintained using individual index cards for each patient that are filed alphabetically. In a manual MPI, each patient who is registered in the facility has an index card in the MPI that is maintained in the health record department. However, an increasing number of health facilities are maintaining computerized Master Patient Indexes and this is described in more detail in Unit 6, Hospital Medical Record Computer Applications. A computerized MPI is maintained using specialized database software. Reference to the computerized MPI will be made in this Unit, when applicable. The basic principles are the same, whether the data collection is done manually or by computer.

 

1. Content of the master patient index

The information contained in this index varies with the needs of the hospital or clinic. Whether the MPI is computerized or manual will determine the amount of data that will be maintained, based on space limitations. In a manual system, only information of an identifying nature necessary for prompt location of a particular health record should be recorded on the patient’s MPI card. A computerized MPI will allow the facility to maintain additional information. Typically, the MPI contains two basic types of data: demographic level and visit level. The privacy necessary for maintaining confidential information should be considered when thinking of recording diagnoses and procedures on a MPI card, and should be avoided. The information recorded should include:

 

Demographic Level

· Internal identification number – number assigned at the time of hospital registration, also called the health record number. It is the number used to file the health records.

· Patient’s full name - family name, given name, middle name or initial, and pertinent suffixes and prefixes

· Date of birth (MM/DD/YYYY or DD/MM/YYYY) - in cases where patients have the same name, the age and date of birth provides additional information for identifying and obtaining the correct health record

· Complete address – street, city, state, zip code/post code, country

· Gender

· Race/Ethnicity

· Other unique identifying information, which will assist the identification of the patient, such as the mother's maiden name, national identification number or social security number. (This information is limited by the amount of space available, i.e., computerized database or index card.)

 

Visit Level

The following additional information may also be listed on the patient's master index card if there is a need and adequate storage available:

· Account number – the billing number used to identify admission or encounter charges

· Admission and discharge dates - for inpatient hospitalizations

· Type of service – inpatient, emergency, outpatient surgery, etc.

· Encounter date or date of service – for outpatient visits

· Disposition – discharged, transferred, or died

· Admitting and/or attending physician's name

The following is an illustration of a MPI card used in a manual master patient index. The information at the top is collected at the time of the first encounter of the patient with the hospital or clinic. If the entries on the card must be handwritten, a pre-printed card will help ensure that the required data elements are recorded and made in a uniform place on the card.

 

Master Patient Index Card

________________________________­_______________________

| DOE, John William MR# 17‑28‑42 |

| | | 17 Western Avenue DOB 02/17/1949 |

| Anytown, Indiana 46321 Sex: M |

| 219-555-3083 |

| |

| Adm Date Dis Date Service Physician Account # |

| |

| 02/14/2004 02/17/2004 IP Smith 04-3332112 |

| 05/16/2004 OPS Jones 04-3332866 |

| |

| |

| | | |

|_______________________________________________________|

 

2. Manual Master Patient Index

a. For inpatients, the procedure for a manual master patient index could be as follows:

1) Each day the admission registration staff notifies the health record department of all patients registered in the facility. This may be done by sending copies of the admission slips for all patients admitted to hospital, which are usually the carbon copies or computer printouts of the registration forms or face sheets.

2) The MPI is checked to see if any of the patients whose names appear on the admission slips have been previously admitted and if they have an index card. If yes, these cards are pulled out and the current admission information is recorded. The demographic information on the index card must also be checked for any changes in name, address, etc.

3) If the patient has had no previous admission, and therefore no card in the MPI, a new index card is prepared.

4) In some hospitals the completed cards of inpatients are filed in a separate file, called the "in‑hospital" or “in-house” file, and remain there until the patient is discharged.

5) At discharge, the MPI card is removed from the "in‑hospital box" and the discharge date is recorded. If a death occurred the date may be recorded in red. The patients' index cards are then filed into the MPI. Given the importance of the integrity and accuracy of this index, many hospitals have a second person check the filed card for accuracy.

b. Organization of the MPI

In the absence of a computerized MPI, special index cards or books or may be used for the listing of patients' names, with index cards being the most preferred.

The most popular and efficient method of maintaining the MPI is on index cards arranged alphabetically in a vertical file with a separate card for each patient. Using this method a single index card can be located readily in one search.

If using a book, it is divided into alphabetical sections. Names are listed under the first letter of the surname in chronological order by date of admission. This method is only feasible for a small facility, but retrieval becomes cumbersome and increasingly difficult for large hospitals, or where the volume of patient admissions or encounters is great, because a strict alphabetical order is maintained. This method is NOT generally recommended for a MPI.

It is not recommended to maintain the master patient index by year of admission or encounter. This is not a good method as patients often forget the date of their last visit, or if they were ever admitted to a particular hospital at all. Much time is lost searching through several sections of the index for the appropriate index card. Nor is it recommended to separate the MPI by sex, that is, to file the cards of male patients in one file and the cards of female patients in another.

c. Methods used for filing

1) Alphabetical ‑ The MPI cards are arranged in the file like the words in a dictionary, following letter by letter of the family name first, then by the given name, and last by the middle name or initial.

· If there are two or more patients with the same family name, cards should be filed alphabetically by the given name. If given names are the same, the middle name or initial should be used to arrange the cards. If the entire name is identical the cards are filed by date of birth, filing the earliest birth date first (the card of the patient who was born first is filed first).

· If an initial is given for a patient's first or middle name, the rule is to "file nothing before something" (Huffman, 1994). Thus, SMITH, P. would come before SMITH, PETER.

· Last names beginning with a prefix or containing an apostrophe are filed in strict alphabetical order, ignoring any spaces or apostrophes. For example, the name O’Leary would be filed as Oleary, and the name Mac Dougal would be filed as Macdougal.

· Compound or hyphenated names are filed letter by letter, as one word; thus Ai‑Min would be filed A‑I‑M‑I‑N.

2) Phonetic ‑ in phonetic filing systems the patients' master index cards are arranged in the file by the first letter of the surname, and then according to sound rather than spelling. Thus all surnames that sound alike, but are spelled differently, are filed together. For example:

SMITH P. LEA S. GREENE, JAMES EDGAR

SMYTH P. LEE S. GREEN, JAMES EDWARD

SMYTHE P. LEIGH S. GREENE, JAMES EDWIN

· While an alphabetical filing system uses 26 letters the "Soundex" system uses only six code numbers.

· Names, which sound alike, but are spelled differently are grouped together in a phonetic patient index, rather than filed letter by letter as in an alphabetical patient index.

· Grouping similar sounding names together lessens the chance of lost index cards due to misspellings and index cards having misspelled names can be more easily located.

d. General filing rules for a Master Patient Index

1) Rules for filing MPI cards must be very detailed. It is not easy to locate medical records if you cannot locate the correct MPI card. Filing rules should be posted near the patients' master index for easy reference.

2) Use of the MPI and filing of the cards should be by authorized personnel only. Careful orientation of new employees to the proper filing procedures is necessary, as is periodic follow‑up on the accuracy of these procedures.

3) The MPI should be a continuous file, that is, not divided into years.

4) A MPI card should be removed from the file only for updating or placing in the in-hospital box.

5) Occasional auditing of the MPI is recommended to monitor filing accuracy. This can be done by having the file clerk place a slightly higher card of a different colour behind each individual card at the time it is filed. A second person, known as the auditor or checker, removes the audit card after checking that each card has been correctly filed. It is useful to audit the filing done by new personnel to ensure that they are applying the rules correctly.

6) A patient whose name has changed since a previous admission will need a new index card. The new index card should be cross‑referenced to the original index card. All information recorded on the original card should be entered on the new card. The original card should be cross‑referenced to the new card.

 

3. Supplies and equipment for a manual Master Patient Index

Index cards, index guides and filing equipment are needed for maintaining a manual MPI.

a) Index cards ‑ 3 x 5 inch cards (7.5 x 12.5 cms) are generally used, but the size may vary depending on the amount of information to be recorded.

Since the MPI is a permanent file, the card must be durable to withstand much handling. Remember, however, that the heavier the card, the more space required in the file.

b) Index guides ‑ Index guides for an alphabetical or phonetic MPI file facilitate the location of an individual patient's card. Being slightly larger than the patient's card, the top of the guide with an initial letter of a common surname is extended above the other cards, thus serving as a guide. Phonetic index guides will require, in addition to guides with initial letters or surnames, subguides indicating basic code numbers. The size and activity of the index will determine the number of guides needed. Sturdy construction of guides is also essential.

c) Filing equipment ‑ Patients' index cards may be filed in cabinets suitable to the card's size. If 3 x 5 inch (7.5 x 12.5 cms) cards are used, they are usually filed in vertical, eight‑drawer, triple compartment file cabinets. A power file is considered feasible when the MPI has more than 500,000 actively used cards. At the touch of a button, a power file delivers the required section of the index to the front of the file for easy access.

 

4. Computerized Master Patient Index

As mentioned earlier, It is also possible to maintain the MPI in a computer. At the time of admission to a facility, the registration staff searches the computer database for a particular patient. If the patient has been in hospital or attended a clinic previously, the patient’s information is displayed on the computer screen. The registrar then updates any demographic information that has changed since the previous admission or visit. If the patient has not been to the hospital previously, the registrar collects the patient demographic information and the system automatically assigns a new registration, or medical record number, and stores this information in its memory. At the time of the patient’s discharge, the date of discharge is entered into the system, thereby completing the current MPI entry. A computerized MPI is discussed in more detail in Unit 6.

 

SUMMARY

The master patient index (MPI) is a permanent listing of all patients who have ever been admitted to, or treated by, the clinic, doctor or hospital. MPI cards should be prepared as soon as possible following the registration of a new patient and not later than 24 hours after the patient's presentation to the clinic or admission office. As the MPI is the key to finding a patient's health record, in a manual system they must be filed promptly in alphabetical or phonetic order.

The type of equipment required will depend upon the type and size of the cards used.

The size generally used is a 3 x 5 inch card (7.5 x 12.5 cms). Regardless of the size of the card, however, only basic identification information needed to promptly locate a

medical record should be recorded. MPI cards must be filed promptly and removed only for updating information. To help find a card guides should be used at regular intervals.

If computerization of hospital information is considered, the registration process and the MPI should be computerized first, if computer storage is available. The patient

demographic and visit information contained on the cards can be stored in a computer

database, and at the time of a patient's admission to, or outpatient encounter at a

hospital, the staff can check the name and file number via a computer terminal in the

office.

 

REVIEW QUESTIONS:

1. What is the purpose of a Master Patient Index?

2. What are the contents of a Master Patient Index?

3. How is a master patient index card prepared? How are data collected?

4. What equipment would be needed for a Master Patient Index?

5. How does the "Soundex" phonetic system work?

When would it be most useful?

6. Why is the Master Patient Index important?

7. How long should a Master Patient Index be kept?

 

REFERENCES:

1. American Health Information Management Association. Practice Brief, “Master Patient (Person) Index (MPI)—Recommended Core Data Elements, “ Journal of the American Health Information Management Association (July 1997).

2. Davis, Nadinia, LaCour, Melissa. Introduction to Health Information Technology.

Philadelphia, PA: W.B. Saunders, 2002.

3. Huffman, Edna K. Health Information Management. 10th ed. Berwyn, IL: Physicians Record Company, 1994.

4. Johns, Merida, ed. Health Information Management Technology: An Applied Approach. Chicago: AHIMA, 2002.

5. Skurka, Margaret. Health Information Management: Principles and Organization for Health Information Services. San Francisco, CA: Jossey- Bass, 2003.

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HL& Medical Record/Information Management

Technical Committee Meeting

Salt Lake City, UT

October 2 & 3, 2001

 

Attendees:

Tuesday Morning: Joint meeting between Medical Records/Health Information and Structured Documents. Wayne Tracy, Harry Rhodes, Robert Dolin, Liora Alschuler, Pavla Fraizer, Calvin Beebe, Bonnie Bakal, Thomson Kuhn, Mike Cassidy, Zijun Zhou,

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Jean Spohn, Sarah Ryan, Paul Biron, Kendza Yen, Holly Walker, Peter Kress, Nancy Orvis

Tuesday Afternoon: Joint meeting between Medical Records/Health Information and Scheduling and Logistics. Harry Rhodes, Anita Benson, Jane Foard, Dave McDowell, Geoffry Roberts, Holly Walker, Jean Spohn

 

Wednesday Morning: Joint meeting between Medical Records/Health Information and Structured Documents. Steve Wagner, Wayne Tracy, Harry Rhodes, Bonnie Bakal, Holly Walker, Igor Gavoyushkin, Calvin Beebe, Paul Biron, Micheal Dauguet, Zijum Zkou

Wednesday Afternoon: HIPAA privacy, meeting requests, domain, and analysis.

Reviewed Domain RMIM for Ballot. Reviewed negative ballot comments. Review and “fix” problem with message model. Respond to individuals that cast negative ballot. Robert Dolin will record the dispositions that will be submitted

The work that will need to be done today regarding the negative ballots: Address minor suggestions to fix little problems, a couple of major issues, and a major issue addressing the CMETs

First negative ballot issue: Section 2.3.1 – No vote- minor: Medical Records has chosen to rename some of the attributes used within their cloned classes. In A_Order_fulfillment (an Act that fulfills an order) the id attribute has been renamed id_filler. In A- Order, the id attribute has been renamed to id placer. These attribute names should not be renamed, otherwise it will cause confusion when trying to relate these attributes to those used in orders and observations, where they have not been renamed.

There is a concern that users will become confused between the id attributes id-filler and id_placer. Solution: after the attribute id place “filler” or “placement” in parenthesis” The goal is clarity.

Disposition Statement: The notion of “placer ID” and “filler ID” are widely understood and accepted. We note the O/O uses “id; (filler id) in their VISIO representation, although not in their HMD or messages.

We should continue to have these attributes named as they currently are (id filler) and disagree with the ballot comments.

Disposition Ballot:

In favor of - 9,

Opposed - 0,

Abstain – 5

Addendum: A subsequent discussion with O/O committee reached the following consensus:

· Will change our “id filler” and “id placer” back to just “id”;

· Will add “(placer)” and “(filler id)”after the id attribute in the VISIO diagram.

· Will add a new column to the HMD that signals the relationship between the “id” field and the previously know “filler id” and “placer id” fields of V2.x

Second negative ballot issue: medical records should use the CMETs developed for patients, providers, encounters, devices, etc. instead of coming up with constructs of their own for these information structures.

Disposition Statement: It’s important to note that the information structures used by medical records were those also used by ANSI/HL7 CDA R1.0 2000, and therefore existed long before these CMETs existed.

We have reviewed the existing CMETs and have not found them to accommodate our requirement. We support the recent decision by the TSC to form a M&M subcommittee to harmonize on CMETs, and we are committed to working with that group to ensure our requirements are met.

We (Bob Dolin) will take our information structures and convert them into CMETs to help the M&M harmonization process. In addition, committee members (Calvin, Wayne, Paul, Pavla)) will review the existing CMETs and offer our comments. We anticipate ultimately using CMETs, once this harmonization has taken place.

Disposition Ballot:

In favor: 11

Opposed: 0

Abstain: 1

Third affirmative vote with comment: RIMS comments, Confidentiality Codes: which are valid for documents? Or are all? Found under CWE (Coded With Exception) Usual, Sensitive, and Highly Sensitive. This discussion surrounded complying with HIPAA mandate to allow the patient to restrict access to Protected Health Information.

Disposition Statement: Unclear why the vocabulary constraints expressed in Rose Tree don’t show up in the published package. We’ll need to investigate this. Seems to be an M& M issue.

We do limit the confidentiality codes use for documents to Normal (usual) restricted, very restricted. Confidentiality can be applied to a document and /or to individual sections within a document.

Ballot:

In favor: 13

Opposed: 0

Abstained: 1

MORNING BREAK.

Pavla Frazier, Student at University of Utah Health Care Informatics Program gave an outline of Clinical Document Ontology Task Force work to date. The overview is presented to the joint committee today to demonstrate work that is being done to standardize document names.

There is not a consistency in Document Names. Which makes the exchange of documents difficult. There is a need for a model for document names.

To facilitate;

Indexing and retrieve

Organizing and Sorting

Content Indexing

How were the document names developed?

From: Document names utilized at: VA hospitals, Mayo Clinic, 3M Intermountain Health Care.

Initial document names: (only include narrative documents such as)

Radiology reports

Pathology reports

Discharge Summaries

Progress notes.

Consultation notes

Wayne: The document names will need to be exhaustive.

Axis development:

The initial axis names came out of the Task Forces initial meeting.

What makes a document name what it is?

Axis 1

1. Event type focus temporal context, service
2. .Focus, subject focus, or object of the note
3. Temporal relationship to care.

Axis 2

Property - always finding

Axis 3

Time aspect – encounter or point in time

Axis 4

Practice Setting – type of environment

Axis 5

Kind of narrative -document

Axis 6

Role of documentor – in relationship to patient or family, i.e. physician.

There was a discussion of the axis methodology and its development. Concerns were raised about the axis names and their use. There was discussion about the need for standardized document names so that confidentiality levels could be assigned by document name. As a standards group HL7 normally addresses current practices. In developing standards to address HIPAA mandates we will be working in an unknown area. Should we leave these issues to the individual facilities to develop their own policies and procedures. HIPAA describes behaviors not data content issues, HL7 should not begin to write standards for these behaviors. We should wait for the implementation guides from HIPAA before beginning any standards work.

Comments on the Ballot - Issue: Consent messages: Should this be done by the Patient Care Committee

Act.cd values for consents: USAM questions.

Disposition Statement: the current ballot does not include consents. If this functionality is desired, we would welcome a proposal. We would address this proposal via listserver and teleconference, with hopes of bringing it forward during the January meeting to include in the ballot.

Medical Records TC has discussed consents in prior sessions (see their prior minutes for details). We would expect these minutes would be reviewed as part of a new proposal.

Disposition Ballot:

In Favor: 15

Opposed: 0

Abstained: 0

Comments on the Ballot –Issue Review: Consent messages: Should this be done by the Patient Care Committee

Act.cd values for consents: USAM questions.

Disposition Statement: the current ballot does not include consents. If this functionality is desired, we would welcome a proposal. We would address this proposal via listserver and teleconference, with hopes of bringing it forward during the January meeting to include in the ballot.

Medical Records TC has discussed consents in prior sessions (see their prior minutes for details). We would expect these minutes would be reviewed as part of a new proposal.

Disposition Ballot:

In Favor: 15

Opposed: 0

Abstained: 0

Comments on the Ballot – Issue Review: Document completion codes should be mapped to the status codes (i.e. the act state transitions) and status coded should be mapped to the events (i.e. which status codes are valid for which events)

Disposition Statement: Document completion codes are orthogonal to status codes. We had this discussion at the July Harmonization (present were Wayne, Bob Dolin, Gunther, and others) and this was the decision reached.

We also specifically discussed the relationship of the MDF triggers to the version 2 triggers in chapter 9 during the July Harmonization meeting with Abdul-Malik. We recognize that a single state transition can result in two of the described Version 3 triggers for our chapters, and we were given clearance by the M&M to proceed with this – largely to ensure that the same set of triggers would exist in version 3 that had been present in Version 2.

Therefore, we find these comments non-persuasive.

Disposition Ballot:

In Favor: 7

Opposed: 0

Abstained: 8

Tuesday Afternoon: Joint meeting between Medical Records/Health Information and Scheduling and Logistics.

The JWG reviewed the minutes of the St. Louis meeting from September 12 & 13, 2001. Anita reviewed the Chart Tracking Model as it currently exists. All current trigger events were reviewed and discussed.

The role of the chart custodian/owner was discussed. Does the Chart Custodian/Owner hold the chart in storage? What has been done to date is define interactions in the chart request model.

There was a discussion of the rational for creating the Trigger Events 07, 08, & 09. These trigger events were created to track the location of new charts. Anita reviewed the rational for forming the JWG. (see past meeting minutes)

JWG Committee discussed next steps: JWG needs to write textual use case models (story board) for each chart request scenario.

In Version 3 use case models have been replaced by Storyboards. A storyboard is the narrative description of how the messaging standards would be applied to a real life situation.

The committee has storyboards for the Australian and Dutch models.

The JWG is in agreement; data definitions still need to be written.

The JWG began an exercise to list all of the data definitions that need to be written.

Data Definitions:

· Patient Name

· Chart defined – A chart is a group of components

· List of Chart Components

· Requestable Components (the part of the record to be requested)

· Date Range – Volumes can be grouped by date. Each component will have a date.

· Physical Volume

· Patient ID

· Requester Location

· Encounter Type

· Service Department

· Document Type

Anita: The JWG needs to be concerned with the categorization of the document and the location of the document. Anita: Suggested that we find out what was done in Structured Documents with regard to document type.

The committee discussed the requesting of charts by service location:

· Radiology

· Laboratory

· Occupational Therapy

· Physical Therapy

· Speech Therapy

· Respiratory Therapy

Each of these service locations would have chart content listings. Which is a listing of the components that make up a service location chart.

The JWG is seeking a means to classify documents for chart tracking. Does a classification of documents already exist within HL7? JWG will ask Bob Dolin what is the intended use of the Practice Settings vocabulary categories. The JWG must ask the question can the Practice Settings be used to classify documents for chart tracking. With in the RIM is there a classification of documents? A review of the RIM vocabulary revealed a Document Type domain definition category. This document type does not seem to be populated with values.

Anita opened a discussion of the possible chart location categories. Are there any absolutes? Do we have to create data definitions for locations? Should we allow each facility to establish unique internal location categories?

Wednesday Morning – Joint Meeting MR/IM and Structured Documents

Ballot comment review: Medical Records, 2.1.1.1.1 Trigger Original Document Notification: Description. “There are multiple approaches by which systems become aware of documents.” What doe it mean?

Disposition Statement: will move to a higher level and clarify

Ballot comment review: Records 2.1.1.2.1 page 8 “and indicates in the document management system that the findings have been authenticated by him.”

Proposed Wording: “and indicates in the document management system that the findings have been authenticated by him.” Or “and indicates in the document management system that the finding has been authenticated by him.”

Disposition Statement: Correct the grammar. Change to “finding(s) has been”

Ballot comment review: 2.1.1.2.1 Comment: Awkward sentence structure, not entirely sure what is the main point(s) of the sentence.

Disposition Statement: agree and will correct.

Ballot comment review: 2.1.1.2.1. In no cases where a document was made available for the patient care will this interaction occur. Awkward sentence, seems like odd use of negatives. Not sure if my correction still conveys the same meaning.

Disposition Statement: we are not sure either, so we prefer to leave is as worded.

Original wording seems to be more prescriptive.

Ballot comment review: Records 2.1.1.2.1 It would be useful if the erroneous document id was supplied and the date and time range when this document was previously available for patient care.

Disposition Statement: Correct grammar. Change to: It would be useful if the erroneous document id was supplied, along with the date and time range when this document was previously available for patient care.

Ballot Comment Review: Records: 2.1.1.3 Question regarding the Document Manager. In the interaction diagram it shows the document manager sending and receiving to itself. I thought the story board said that a document manager from a lab was talking to document manager in the hospital.

Disposition Statement: If there are two instances of the same application role, are we supposed to include two applications communicating or one application with a recursive communications?

We’ll ask the UML experts and do whatever M& M recommends here.

Ballot: Does anyone object to grouping the ballot comments together for a single vote.

In Favor: 10

Opposed: 0

Abstained: 0

Ballot comment review: Records 2.3.1 Revamp R-MIM to use newest stencils, and ensure that it is validatable against the RIM. (some missing mandatory fields, convention for handling alias names, etc.) Also suggest re-organizing the R-MIM to avoid crossing lines (flipping the Roles may help this).

Disposition Statement: Will follow the M&M recommendations.

Ballot:

In Favor: 10

Opposed: 0

Abstained: 0

Addendum: During the M&M wrap-up meeting 10/4, it was clear that the new expectation is to use the latest VISIO stencil just as Lloyd has requested us to do.

Ballot comment review: Records 2.3.1 R. originating device should have a class_cd of DEV. It should also have a name or id (consider using the CMET)

Disposition Statement: See response below on our approach to CMETs. We will include the device CMET in those we submit to the CMET task group.

In the current RIM and current Rose Tree, there is no value of “DEV” for role class codes. We do use the value of “DEV” in the Device clone. So, unless the vocabulary has changed and isn’t properly reflected in Rose Tree, we’d leave the class ed values as they currently stand. Also, R_originating device does have an id attribute, so we’re not sure we understand the comment.

Ballot:

In Favor: 10

Opposed: 0

Abstained: 0

Ballot Comment Review: records 2.3.1 R individual healthcare provider under the P_ structure_originator should have a name and/or id (Consider using Ident provider CMET)

Disposition Statement: The comment is unclear. Clone R Individual healthcare provider has an id attribute , and clone Person named person has a “nm” attribute. So, no change for now.

Ballot:

In Favor: 10

Opposed 0

Abstained: 0

Ballot comment Review: Records 2.3.1 Observation as Multimedia _document_content should have a ‘cd’ attribute to specify the type of document. The value attribute should be identified as datatype ED.

Disposition Statement: This clone represents a multimedia object in a document. It is always part of a document. (represented by the AC Clinical document class.) We will add clarifying narrative to this effect. There is no need for a ‘cd’ attribute.

The value is ED, and we’ll follow M&M recommendations as to how to reflect this in the VISIO diagram.

Ballot:

In Favor: 10

Opposed: 0

Abstained: 0

Ballot comment review: records 2.3.1, What is the reason for distinguishing between narrative and multimedia documents? Both can be easily handled by the ED datatype of the txt attribute.

Disposition Statement: Will add clarifying text. These are both components of documents – one for narrative, one for multimedia. We will add clarifying narrative to this effect. Will change the datatype of A_Narrative_document_ content txt to “ST”

Ballot:

In Favor: 10

Opposed: 0

Abstained: 0

Ballot Comment Review: Records 2.31, the inclusion of P_Participant seems a little open ended. Consider restricting it to a more specific list of “other” participation types.

Disposition Statement: Will exclude those type _cd values that are not applicable.

Will add the function_cd attribute to the P_participant clone. In particular: will add “CON” to P_Provider, and will the type _cd of P_participant to “REF”, “BBY”, “MTH”, “ServiceActor”, “ServiceTargetType”.

Ballot:

In Favor: 9

Opposed: 0

Abstained: 0

 

MORNING BREAK

Vocabulary Word in response to the comments on the class entitled Participation Type. The work of the JWG is to eliminate unnecessary person type code classes. There was a group discussion of the code for ‘witness’ Coded as: witness (WIT). A reason for controlling the person that is coded is the medical legal requirement to protect the content of the medical record document. This information on participant would be in the header of the document. Bob Dolin to post suggested exclusion list on the HL7 Listserv for comment.

Exclusion List:

· Consenter, Coded as Consenter (CNS)

· Reviewer, Coded as Reviewer (REV)

· Witness, Coded as Witness (WIT)

· Call Back Contact, Coded as Call Back Contact (CBC)

· Data Entry Person, Coded as data entry person (ENT)

· Informant, Coded as Informant (INF)

· Tracker, Coded as Tracker

· Escort, Coded as Escort

· Origination Device, Coded as Origination Device (ODV)

· Product, code as product (PRD)

· Donor, code as donor (DON)

· Proxy, code as proxy (NOK)

· Patient Subject

Leave on the list:

· Supervisor, Coded as Supervisor (SPV)

· Verifier, Coded as Verifier (VRF)

· Consultant, Coded as Consultant (CON) – this should be a function code and nor a type code.

· Referrer

· Receiver, Code as Receiver (RCV)

· Baby , Code as Baby (BBY)

· Mother, Code as Mother (MTH)

· Service Actor,

Wednesday Afternoon: HIPAA privacy, meeting requests, domain, and analysis.

Agenda for the HL7 Medical Record/information Management Technical Committee Meeting in San Diego, CA, January 8 & 9, 2002

Agenda Items:

Tuesday AM:

Joint Work Group meeting MR/IM TC and Structured Documents. V3 Ballot 2 preparation.

Tuesday PM:

Joint meeting between Medical Records/Health Information and Scheduling and Logistics. Advance work in chart tracking model, develop story boards and data definition.

Wednesday AM:

Joint Work Group meeting MR/IM TC and Structured Documents. V3 Ballot 2 preparation.

Wednesday PM:

Joint meeting between Medical Records/Health Information and Scheduling and Logistics. Advance work in chart tracking model, develop story board and data definitions.

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National Standards for the structure and content of medical records.

The Medical Record Keeping Standards Programme of the Health Informatics Unit at the Royal College of Physicians, London.

 

 

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Prof. Iain Carpenter, Health Informatics Unit, Royal College of Physicians, London/Centre for Health Service Studies, University of Kent, Canterbury

Mala Bridgelal Ram, Health Informatics Unit, Royal College of Physicians, London

Professor John Williams, Director, Health Informatics Unit, Royal College of Physicians, London/ School of Medicine, Swansea University

Patient medical records serve two principal purposes. The first is to support direct patient care by acting as an aide memoir for clinicians and supporting clinical decision making. The second is to provide a reliable source of data to support clinical audit, research, resource allocation and performance planning. In the UK, the link between the two is the coding of diagnoses and procedures during a hospital stay that is then returned centrally for analysis and publication in the Hospital Episode Statistics. We describe how the Health Informatics Unit at the Royal College of Physicians in London has co-ordinated the development of nationally agreed standards for the structure and content of medical records that have been agreed for all hospital specialties.

The programme emerged from a project aiming to compare the performance of gastro-enterology services between hospitals by analysing Hospital Episode Statistics (HES). The study concluded that it was impossible, possibly because of errors in the coding of diagnoses and procedures imprecisely recorded in medical notes. An audit of 149 sets of medical notes from 5 hospitals found that there was such variability between hospitals in how records are structured and organised that a comparative audit was not possible. A subsequent literature search for evidence of the benefits of standardised medical notes, though patchy in coverage, demonstrated benefits to patient safety and care outcomes, as well as likely improvement in ease and accuracy of clinical coding. This initiated the Record Standards programme at the Health Informatics Unit (HIU). The national programme to develop an Electronic Patient Record (EPR) for the National Health Service (NHS) in England gave added weight and urgency to the work, as an EPR requires standardisation of data, ideally reflecting best clinical practice rather than requirements of a computer system.

The goal was to develop consensus and evidence based structure and content standards for medical notes that would reflect professional best practice and be acceptable to all medical and surgical hospital services.

Our first step was to draft content and process standards for medical records from both the literature review and a review of standards published by medical professional bodies. The standards covered generic issues applicable to all medical notes as well as headings to standardise the structure of admission, handover and discharge records. The HIU separated the generic and content standards and consulted widely, seeking the views of practising doctors and professional and policy bodies. Generic Medical Record Keeping standards were published by the College in 2007[1].

The development of the admission, handover and discharge record keeping standards started with a poll of practising hospital doctors to gauge the enthusiasm for standardising notes structure. The question asked was ‘Should the same, standardised headings be used in the proforma for acute medical admissions in all NHS hospitals?’. In the first of these, conducted by Doctors.net, 2:1 responded in favour, a second poll, of Members and Fellows of the RCP found 4:1 in favour. Both polls were closed at 1,000 responses (Carpenter et al, 2007).

With evident support for the proposal confirmed, examples of admission clerking documents from 36 NHS hospitals were used to produce draft headings which were then revised in a series of workshops and then put out to consultation in on-line questionnaire. The workshops and on-line questionnaires included patients and carers from the RCP Patient Carer Network. Over 3,000 doctors responded to the questionnaire and contributed over 1,500 written comments. Of those who responded to the questionnaire, over 90% were in favour of a common structure for the whole NHS.

A further series of workshops and an updated literature review developed headings for use in documents to support handover between medical teams and in discharge documents for when patients leave hospital, the latter with specific input from General Practitioners in primary care. The on-line handover and discharge consultations each generated around 1,500 completed questionnaires.

At the same time, the Presidents of the all the UK Medical Royal Colleges and specialist societies were contacted and asked to identify nominees who would examine, with their colleagues, the headings for the different types of records from the perspective of their own specialty. Their responses were fed into revised headings which were then used to structure paper proformas to test the headings in practice. The product of the exercise was piloted in hospitals [admission (10), handover(11) and discharge(8)], the discharge summary pilot included GPs who received discharge summaries using the standardised headings.

On April 17^th 2008, the final revised standards were ‘signed off’ by the Academy of Medical Royal Colleges, attended by the Presidents from all colleges, including surgical, mental health and child health. They were passed as fit for purpose with observations from psychiatry and paediatrics that although the information that they required was different from and additional to that covered by the standardised headings, their requirements could be accommodated within the proposed structure standards.

The standards have now been submitted to NHS Connecting for Health which is responsible for the development of the EPR in England. Work on definitions that will meet the rigorous requirements for IT implementation is underway. Once completed they will be submitted to the NHS Information Standards Board for Health and Social Care following which all IT system suppliers will be required to use them for their EPR solutions. Many hospitals and IT suppliers are already implementing them in both paper and electronic format.

The project has been enthusiastically received by a very wide range of organisations including the IT industry which see them as the means for rationalising their clinical information system applications. The NHS Litigation Authority, which provides the clinical incident indemnity for NHS providers, are incorporating them into their Risk Management Standards for providers and the NHS Care Quality Commission who register all NHS providers will reference them in their standards required for registration. They are being incorporated into the medical undergraduate and post graduate training curricula and will likely be referenced in the General Medical Council ‘Tomorrow’s Doctors’ standards document that describes the standards for knowledge, skills, attitudes and behaviours that medical students should learn at UK medical schools. The standards are recommended for use in IT systems in Scotland and are being introduced in Wales.

The NHS Digital and Health Information Policy Directorate has published a two part clinician’s guide to the standards.

v Part 1 describes the rationale for the process of developing and introducing the national professional record keeping standards. It also lists the expected benefits from their introduction.

v Part 2 contains the Generic Medical Record Keeping Standards and the structure and content standards for admission, handover and discharge documents.

The Guide can be downloaded as pdf’s or free hardcopies ordered on line at : www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/clinicians-guides.aspx

[1] Carpenter, Iain; Bridgelal Ram, Mala; Croft, Giles P; Williams, John G, 2007. Medical records and record-keeping standards. Clinical Medicine: 7(4):328-331

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Medical Record Release

 

Patient Information (please print)

Patient Name:   ____________________________    Date of Birth:    ________________________ 

Address:        ______________________________________________________________________ 

Telephone #:     ____________________________    Medical Record #:   _____________________

 

Release Information to

Name/Facility:       __________________________________________________________________

Address:        ______________________________________________________________________

                                                                  

Information to be Released (check all that apply)

* Clinic Visit Notes             * Imaging Reports     * Pathology Reports

* Complete Chart     * Lab Reports       * Other:   _________________________ 

* Discharge Summary        * Operative Reports                          _________________________

 

Authorization (authorization remains valid for 90 days from date of signature)

Patient Signature:     _______________________________________     Date:   ________________

Parent/Guardian:      _______________________________________     Date:   ________________

 

 

This medical record may contain certain sensitive or statutorily protected information.
Please indicate the information you would like released. A separate signature is required.

* Mental Health Information                           * Social Service Information

* Domestic Violence Information                     * Sexual Assault Information

* Alcohol/Drug Abuse Information                   * Sexually Transmitted Diseases

Patient Signature:     _______________________________________     Date:   ________________

Parent/Guardian:      _______________________________________     Date:   ________________ 

 

 

This medical record may contain HIV testing and AIDS treatment information. I authorize the release of this information to the person/facility named in this form, for a single release only.

Patient Signature:     _______________________________________     Date:   ________________

Parent/Guardian:      _______________________________________     Date:   ________________ 

At first glance, medical records appear to be one of the few truly confidential areas in our lives. Laws in many states, including California, and the age-old tradition of doctor-patient privilege seem to make it difficult for others to gain access to medical records. But the laws contain exemptions. And the right to confidentiality is often lost in return for insurance coverage. In short, you may have a false sense of security.

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What do my medical records contain?

Medical records are created when you receive treatment from a health professional such as a physician, nurse, dentist, chiropractor or psychiatrist. Records may include your medical history, details about your lifestyle (such as smoking or involvement in high risk sports), and family medical history. In addition, your records contain laboratory test results, medications prescribed, and other reports which indicate the results of operations and other medical procedures.

 

Who has access to my medical records?

Your medical information is shared by a wide range of people both in and out of the health care industry. Generally, access to your records is obtained when you agree to let others see them. You have probably signed "blanket waivers" or "general consent forms" when you have obtained medical care. When you sign such a waiver, you allow the health care provider to release your medical information to insurance companies, government agencies and others.

 

1. Insurance companies require you to release your records before they will issue a policy or make payment under an existing policy. Medical information gathered by one insurance company may be shared with others through the Medical Information Bureau (see below).

 

2. Government agencies may request your medical records to verify claims made through Medicare, MediCal, Social Security Disability and Workers Compensation.

 

3. The Medical Information Bureau (MIB) is a central database of medical information. Approximately 15 million Americans and Canadians are on file in the MIB's computers. Over 750 insurance firms use the services of the MIB primarily to obtain information about life insurance and individual health insurance policy applicants. A decision on whether to insure you is not supposed to be based solely on the MIB report. Visit the MIB web site at www.mib.com

 

The MIB does not have a file on everyone. But if your medical information is on file, you will want to be sure it is correct. You can obtain a copy ($8) by writing to:

Medical Information Bureau
P.O. Box 105, Essex Station
Boston, MA 02112
or call (617) 426-3660.

4. Employers usually obtain medical information about their employees by asking employees to authorize disclosure of medical records. This can occur in several ways.

• When medical insurance is paid by employers, they may require insurance companies to provide them with copies of employees' medical records.
• Self-insured businesses establish a fund to cover the insurance claims of employees. Since no third party is involved, the medical records that would normally be open for inspection by an insurance company are accessible to the employer. Most large corporations are self-insured.

Unfortunately, the laws in only a few states require employers to establish procedures to keep employee medical records confidential. (For example, California Civil Code §56.)

According to the federal Americans with Disabilities Act (ADA, 42 USC §12101 et seq.), in workplaces with more than 25 employees: ADA text at Web, www.independentliving.org/LibArt/ada.html

• Employers may not ask job applicants about medical information or require a physical examination prior to offering employment.
• After employment is offered, an employer can only ask for a medical examination if it is required of all employees holding similar jobs.
• If you are turned down for work based on the results of a medical examination, the employer must prove that it is physically impossible for you to do the work required.

Violations of the ADA should be brought to the attention of the U.S. Equal Employment Opportunity Commission (EEOC). The EEOC's phone number is listed in the U.S. Government section in the white pages of the phone book.
Web: www.eeoc.gov/laws/ada.html

 

5. Your medical records may be subpoenaed for court cases. If you are involved in litigation, an administrative hearing or worker's compensation hearing and your medical condition is an issue, the relevant parts of your medical record may be copied and introduced in court.

 

6. Other disclosures of medical information occur when medical institutions such as hospitals or individual physicians are evaluated for quality of service. This evaluation is required for most hospitals to receive their licenses. Your identity is generally not disclosed when medical practices are evaluated. Occasionally, your medical information is used for health research and is sometimes disclosed to public health agencies like the Centers for Disease Control. Specific names are usually not included with the information.

 

7. Medical information may be passed on to direct marketers when you participate in informal health screenings. Tests for cholesterol levels, blood pressure, weight and physical fitness are examples of free or low-cost screenings offered to the public. Screenings are often conducted at pharmacies, health fairs, shopping malls or other nonmedical settings. The information collected may end up in the data banks of businesses which have products to sell related to the test. Use caution when participating in such screenings. Ask what will be done with the information and who will have access to the test results.

 

8. A tremendous amount of health-related information is found on the Internet. Many Usenet news groups and "chat" rooms are available for individuals to share information on specific diseases and health conditions. Web sites dispense a wide variety of information. There is no guarantee that information you disclose in any of these forums is confidential. Use a pseudonym and a non-name specific electronic mail address. Avoid registering your name on web sites.

 

Is there any way to protect the privacy of my medical records?

Currently, there are no comprehensive laws regarding medical records privacy. Here are some methods which may limit others' access to your medical records:

1. When you are asked to sign a waiver for the release of your medical records, try to limit the amount of information released. Instead of signing the "blanket waiver," cross it out and write in more specific terms.

• Example of blanket waiver: I authorize any physician, hospital or other medical provider to release to [insurer] any information regarding my medical history, symptoms, treatment, exam results or diagnosis.
• Edited waiver: I authorize my records to be released from [X hospital, clinic or doctor] for the [date of treatment] as relates to [the condition treated].
•  

2. If you want a specific condition to be held in confidence by your personal physician, bring a written request to the appointment that revokes your consent to release medical information to the insurance company and/or to your employer for that visit; you must also pay for the visit yourself rather than obtain reimbursement from the insurance company. To be especially certain of confidentiality, you may need to see a different physician altogether and pay the bill yourself, forgoing reimbursement from the insurance company.

 

3. Use caution when filling out medical questionnaires. Find out if you must complete it, what its purpose is, and who will have access to the information that is compiled. Also, before participating in informal health screenings, find out what uses will be made of the medical information that is collected. Use the same caution when visiting Web sites and when participating in online discussion groups.

 

4. Ask your health care provider to use caution when photocopying portions of your medical records for others. Sometimes more of your medical record is copied than is necessary.

 

5. If your records are subpoenaed for a legal proceeding, they become a public record. Ask the court to allow only a specific portion of your medical record to be seen or not to be open at all. A judge will decide what parts, if any, of your medical record should be considered private. After the case is decided, you can also ask the judge to "seal" the court records containing your medical information.

 

6. Find out if your health care provider has a policy on the use of cordless and cellular phones and fax machines when discussing and transmitting medical information. Cordless and cellular telephones are not as private as standard "wired" telephones. Because they transmit by radio wave, phone conversations can be overheard on various electronic devices. (See the Privacy Rights Clearinghouse Fact Sheet No. 3, "Wireless Communications.")

Fax machines offer far less privacy than the mail. Frequently many people in an office have access to fax transmissions. Staff members at all levels of the organization should take precautions to preserve confidentiality when sending and receiving medical documents by fax machine. (See PRC Fact Sheet No. 12, "Checklist of Responsible Information-Handling Practices.")

 

How do I get access to my own medical records?

In California and about half the states, health care providers must allow patients (or their representatives) to access and obtain copies of their own medical records. (California Health and Safety Code §123100). This includes doctors' offices, hospitals, mental health facilities and clinics. Generally the health facility must charge a "reasonable" fee for copying records. If you received care in a federal medical facility, you have a right to obtain your records under the federal Privacy Act of 1974 (5 USC §552a. Web access at www.usdoj.gov/foia/privstat.htm).

Most medical offices ask that you make your request in writing. If the health care provider will not release your records, ask for a written letter of denial. Then contact a patients' rights group, the local medical society, the state medical board or an attorney for further assistance. Generally, a request for disclosure may be denied if the health care provider believes the information will be harmful to the patient. In that case, the health care provider is usually required to disclose the record to a physician of the patient's choice. Denial of health records most often occurs with mental health records.

 

The future of medical records privacy

There is much debate over the future of the health care industry. Instead of your doctors each keeping their own records, there is likely to be a central computer file with your complete medical history stored in a regional or national database. Some say this will make the system more efficient, help you keep track of your personal information, and allow you to monitor your records for mistakes. However, privacy advocates are concerned about secondary uses of this medical information, employer access and unauthorized access.

 

The 1996 federal Health Insurance Portability and Accountability Act mandates a national healthcare ID number for all citizens. (Web: http://aspe.os.dhhs.gov/admnsimp/pl104191.htm) It also calls for the development of a federal privacy protection law by August 21, 1999, or in its absence, regulations adopted by the U.S. Department of Health and Human Services. There is considerable debate surrounding these and other issues. If you have an opinion or concern, contact your state and federal legislators.

 

For more information

A leader in fighting for patients’ privacy rights is the National Coalition for Patient Rights
405 Waltham St., Suite 218
Lexington, MA 02173
Phone: (781) 861-0635
Web: www.nationalcpr.org

The Web site of the American Health Information Management Association includes a white paper on medical records privacy and other useful information, www.ahima.org.
Contact AHIMA at 919 N. Michigan Ave.
Chicago IL 60611-1683.
Phone: (800) 335-5535.

For help with the Americans with Disabilities Act, call the nearest Technical Assistance Center, (800) 949-4232.
Web: www.pacdbtac.org or www.adata.org

Contact the Privacy Advocate of the U.S. Dept. of Health and Human Services regarding privacy-related programs of the DHHS: 200 Independence Ave., SW, Washington, D.C. 20201.
Phone: (202) 690-5896.
Web: www.dhhs.gov

The Health Privacy Project of Georgetown University is a resource for public policy information, especially federally-mandated privacy protection due by August 21, 1999.
Web: www.healthprivacy.org
The Web site includes information on federal privacy legislation.

For health privacy-related disputes in California, contact the county medical society or the Medical Board of California at (800) 633-2322.
Web: www.medbd.ca.gov

For information about access to health records, visit the Web site of the California Medical Association, www.cmanet.org (look for "Free Legal Information").

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	ID _________

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Instructions: Please review the infant and maternal medical records

Please review the maternal medical record for questions 1-15:

1.    What is the mother’s month and year of birth?   ___/_________

2.    What is the ethnicity of the mother?

 Hispanic or Latino                     Not Hispanic or Latino        unknown

3.    What is the race of the mother? Please check all that apply.

 White  African American   Asian   American Indian or Alaska

Native  Native Hawaiian or Other Pacific Islander  Other or unknown

4.    Mother’s Insurance Status?

 Private  Medicaid  Other or Unknown

5.    Please indicate admission date ___/___/_____  and time ___:___ am/pm

 

6.    Was there a prenatal HBsAg (hepatitis B surface antigen) test performed prior to admission?

 Yes              No                         

7.    What was the prenatal HBsAg test date? ___/___/_____   Not documented

8.    What was the prenatal HBsAg test result?

 Positive  Negative  Not documented     

9.    How was HBsAg status of mother documented?

 Copy of laboratory report

 Clinician transcription of information into medical record from other source

 Other, describe: _____________________________________

10.  Was there an HIV test performed prior to admission?

 Yes              No                                      

11.  What was the prenatal HIV test date? ____/___/____  Not documented

Consider adding additional questions on syphilis, GBS, etc.

12.  Was there an HBsAg test performed during the hospital stay?

 Yes              No                                                 

13.  What was the result of the HBsAg test performed during the hospital stay?

 Positive       Negative     Not documented

14.  Was there an HIV test performed during the hospital stay?

 Yes              No             

15.  Type of attending provider

 Obstetrician  Family practitioner  Other or unknown

Please review neonatal medical record for Questions 16-29:

16.  Please indicate infant’s date of delivery ___/___/_____  and time of delivery ___:___ am/pm

17.  Did the infant weigh <2,000 grams at birth?

             Yes                          No                         

18.  Is there a recorded maternal HIV test result?

 Yes                          No             

19.  Is there a recorded maternal HBsAg test result?

 Yes                          No                         

20.  What was the maternal HBsAg test result?

 Positive                   Negative

21.  Was HBIG (hepatitis B immune globulin) given to the infant?

 Yes; date ___/___/_____   Time ___:___ am/pm

 No

22.  Was infant HBIG administered as a result of hospital pre-printed admission orders*?

 Yes                                No                         

23.  If there were no hospital pre-printed admission orders*, was infant HBIG administered as a result of a specific physician order?

 Yes                                No                         

24.  Was hepatitis B vaccine given to the infant?

 Yes                                No             

25.  Please indicate date of hepatitis B vaccine  ___/___/_____  and time of  administration ___:___ am/pm

26.  Was hepatitis B vaccine administered as a result of hospital pre-printed admission orders*?

 Yes                                No                         

27.  If there were no hospital pre-printed admission orders*, was hepatitis B vaccine administered as a result of a specific physician order?

 Yes                                No                         

28.  Was there any specific order in the neonatal medical record not to vaccinate against hepatitis B virus?

 Yes                                No; end survey     

29.  If there was an order not to vaccinate, what was documented as the reason for not vaccinating? Please check all that apply.

 Infant was <2,000 grams at birth

 Infant was not medically stable

 Mother was HBsAg negative

 Guardian refused

 No reason documented

 Other reason; please specify below:

Thank you for your participation!

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