tag:blogger.com,1999:blog-5313581234588792412024-03-08T00:22:43.109-08:00MEDICAL RECORDRafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.comBlogger32125tag:blogger.com,1999:blog-531358123458879241.post-68234964678384084542011-09-02T01:35:00.000-07:002011-09-02T01:35:38.814-07:00animation<a href="http://www.facebook.com/photo.php?pid=295706&id=135612266516793" id="myphotolink"><img id="myphoto" src="http://a3.sphotos.ak.fbcdn.net/hphotos-ak-ash4/302463_166509230093763_135612266516793_295802_7798194_n.jpg" /></a><br />
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Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com1tag:blogger.com,1999:blog-531358123458879241.post-44806754485508858562011-08-28T05:11:00.001-07:002011-08-28T05:11:47.863-07:00INTERNATIONAL FEDERATION OF HEALTH RECORDS ORGANIZATIONS (IFHRO) Education Module for Health Record Practice<p align="center"><b>INTERNATIONAL FEDERATION OF HEALTH RECORDS ORGANIZATIONS (IFHRO)</b></p> <p align="center"><b></b></p> <h3 align="center">Education Module for Health Record Practice</h3> <p align="center"><b>UNIT 2 - PATIENT IDENTIFICATION, REGISTRATION AND THE MASTER PATIENT INDEX</b></p> <p align="center"><strong></strong></p> <p align="center"><strong></strong></p> <p align="justify">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.</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> <p align="justify"> </p> <p align="justify"><b><u>OBJECTIVES</u></b>:</p> <p align="justify">At the conclusion of this unit the participant should be able to:</p> <p align="justify">1. Discuss the importance of complete and accurate patient identification</p> <p align="justify">2. State the purpose of a master patient index (MPI)</p> <p align="justify">3. List the items, which should be included in a master patient index </p> <p align="justify">4. Develop and implement a master patient index (MPI)</p> <p align="justify">5. Trace the flow of a patient's index card from admission to discharge</p> <p align="justify">6. Use alphabetical or phonetic filing rules to correctly file cards in a manual master patient index</p> <p align="justify">7. Discuss the need for cross‑referencing names in a master patient index</p> <p align="justify">8. State the types of supplies and equipment commonly used for maintenance of a manual master patient index (MPI).</p> <p align="justify"> </p> <p align="justify"><b>A. PATIENT IDENTIFICATION</b></p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">This section of the medical record should contain at least the following information:</p> <p align="justify">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.</p> <p align="justify">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.)</p> <p align="justify">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.</p> <p align="justify">4. Name, address and telephone number of nearest relative (next of kin) or friend.</p> <p align="justify">5. Name and address of attending doctor, and name and address of referring doctor, if applicable.</p> <p align="justify">6. Occupation, name and address of patient's employer.</p> <p align="justify">7. Date and time of admission or encounter, and name of unit or clinic.</p> <p align="justify">8. Details of health insurance and medico‑legal information if appropriate.</p> <p align="justify">The above information should be obtained from the patient, if possible, or otherwise from the person accompanying the patient to the hospital or clinic.</p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b>B. PATIENT REGISTRATION</b></p> <p align="justify">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.</p> <p align="justify">Important aspects of patient registration are:</p> <p align="justify">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.</p> <p align="justify">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:</p> <p align="justify"><u>Health Record</u> <u>Patient's Name</u> <u>Date of Issue</u> <u>Doctor/</u></p> <p align="justify"><u>Number</u> <u>Clinic</u></p> <p align="justify">10 26 42 John Doe 01/01/2004 Dr. Lee</p> <p align="justify">This register is maintained as a control to avoid duplication of numbers and the issuing of the same number to two people.</p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b>C. MASTER PATIENT INDEX (MPI)</b></p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b>1. Content of the master patient index</b></p> <p align="justify">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:</p> <p align="justify"> </p> <p align="justify"><b>Demographic Level</b></p> <p align="justify">· 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.</p> <p align="justify">· Patient’s full name - family name, given name, middle name or initial, and pertinent suffixes and prefixes</p> <p align="justify">· 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</p> <p align="justify">· Complete address – street, city, state, zip code/post code, country</p> <p align="justify">· Gender</p> <p align="justify">· Race/Ethnicity</p> <p align="justify">· 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.)</p> <p align="justify"> </p> <p align="justify"><b>Visit Level</b></p> <p align="justify">The following additional information may also be listed on the patient's master index card if there is a need and adequate storage available:</p> <p align="justify">· Account number – the billing number used to identify admission or encounter charges</p> <p align="justify">· Admission and discharge dates - for inpatient hospitalizations</p> <p align="justify">· Type of service – inpatient, emergency, outpatient surgery, etc.</p> <p align="justify">· Encounter date or date of service – for outpatient visits</p> <p align="justify">· Disposition – discharged, transferred, or died</p> <p align="justify">· Admitting and/or attending physician's name</p> <p align="justify">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. </p> <p align="justify"> </p> <p align="justify"><u>Master Patient Index Card</u></p> <p align="justify">_______________________________________________________</p> <p align="justify">| DOE, John William MR# 17‑28‑42 |</p> <p align="justify">| | | 17 Western Avenue DOB 02/17/1949 |</p> <p align="justify">| Anytown, Indiana 46321 Sex: M |</p> <p align="justify">| 219-555-3083 |</p> <p align="justify">| |</p> <p align="justify">| <u>Adm Date Dis Date Service Physician Account # </u>|</p> <p align="justify">| |</p> <p align="justify">| 02/14/2004 02/17/2004 IP Smith 04-3332112 |</p> <p align="justify">| 05/16/2004 OPS Jones 04-3332866 |</p> <p align="justify">| |</p> <p align="justify">| |</p> <p align="justify">| | | |</p> <p align="justify">|_______________________________________________________|</p> <p align="justify"> </p> <p align="justify"><b></b></p> <p align="justify"><b>2. Manual Master Patient Index</b></p> <p align="justify">a. For inpatients, the procedure for a manual master patient index could be as follows:</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">3) If the patient has had no previous admission, and therefore no card in the MPI, a new index card is prepared.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify"><b></b>b. Organization of the MPI</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify"><b></b>c. Methods used for filing</p> <p align="justify">1) <u>Alphabetical</u> ‑ 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.</p> <p align="justify">· 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).</p> <p align="justify">· 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.</p> <p align="justify">· 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.</p> <p align="justify">· Compound or hyphenated names are filed letter by letter, as one word; thus Ai‑Min would be filed A‑I‑M‑I‑N.</p> <p align="justify">2) <u>Phonetic</u> ‑ 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:</p> <p align="justify">SMITH P. LEA S. GREENE, JAMES EDGAR</p> <p align="justify">SMYTH P. LEE S. GREEN, JAMES EDWARD</p> <p align="justify">SMYTHE P. LEIGH S. GREENE, JAMES EDWIN</p> <p align="justify"><b></b></p> <p align="justify">· While an alphabetical filing system uses 26 letters the "Soundex" system uses only six code numbers.</p> <p align="justify">· 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.</p> <p align="justify">· 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.</p> <p align="justify">d. General filing rules for a Master Patient Index</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">3) The MPI should be a continuous file, that is, not divided into years.</p> <p align="justify">4) A MPI card should be removed from the file only for updating or placing in the in-hospital box.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b>3. Supplies and equipment for a manual Master Patient Index</b></p> <p align="justify">Index cards, index guides and filing equipment are needed for maintaining a manual MPI.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b>4. Computerized Master Patient Index</b></p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b><u>SUMMARY</u></b></p> <p align="justify"><b><u></u></b></p> <p align="justify">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.</p> <p align="justify">The type of equipment required will depend upon the type and size of the cards used. </p> <p align="justify">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 </p> <p align="justify">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.</p> <p align="justify">If computerization of hospital information is considered, the registration process and the MPI should be computerized first, if computer storage is available. The patient </p> <p align="justify">demographic and visit information contained on the cards can be stored in a computer </p> <p align="justify">database, and at the time of a patient's admission to, or outpatient encounter at a </p> <p align="justify">hospital, the staff can check the name and file number via a computer terminal in the </p> <p align="justify">office.</p> <p align="justify"> </p> <p align="justify"><b><u>REVIEW QUESTIONS:</u></b></p> <p align="justify">1. What is the purpose of a Master Patient Index?</p> <p align="justify">2. What are the contents of a Master Patient Index?</p> <p align="justify">3. How is a master patient index card prepared? How are data collected?</p> <p align="justify">4. What equipment would be needed for a Master Patient Index?</p> <p align="justify">5. How does the "Soundex" phonetic system work?</p> <p align="justify">When would it be most useful?</p> <p align="justify">6. Why is the Master Patient Index important?</p> <p align="justify">7. How long should a Master Patient Index be kept?</p> <p align="justify"> </p> <p align="center"><b>REFERENCES:</b></p> <p align="justify">1. American Health Information Management Association. Practice Brief, “Master Patient (Person) Index (MPI)—Recommended Core Data Elements, “ <i>Journal of the American Health Information Management Association</i> (July 1997).</p> <p align="justify">2. Davis, Nadinia, LaCour, Melissa. <i>Introduction to Health Information Technology</i>.</p> <p align="justify">Philadelphia, PA: W.B. Saunders, 2002. </p> <p align="justify">3. Huffman, Edna K. <i>Health Information Management</i>. 10th ed. Berwyn, IL: Physicians Record Company, 1994.</p> <p align="justify">4. Johns, Merida, ed. <i>Health Information Management Technology: An Applied Approach.</i> Chicago: AHIMA, 2002.</p> <p align="justify">5. Skurka, Margaret. <i>Health Information Management: Principles and Organization for Health Information Services.</i> San Francisco, CA: Jossey- Bass, 2003.</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-41067825804038310162011-08-28T05:07:00.001-07:002011-08-28T05:07:51.806-07:00HL& Medical Record/Information Management Technical Committee Meeting Salt Lake City, UT<p align="center">HL& Medical Record/Information Management</p> <p align="center">Technical Committee Meeting</p> <p align="center">Salt Lake City, UT</p> <p align="center">October 2 & 3, 2001</p> <p align="justify"> </p> <p align="justify"><b>Attendees:</b></p> <p align="justify"><b>Tuesday Morning: Joint meeting between Medical Records/Health Information and Structured Documents. </b>Wayne Tracy, Harry Rhodes, Robert Dolin, Liora Alschuler, Pavla Fraizer, Calvin Beebe, Bonnie Bakal, Thomson Kuhn, Mike Cassidy, Zijun Zhou,</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> <p align="justify"> </p> <p align="justify">Jean Spohn, Sarah Ryan, Paul Biron, Kendza Yen, Holly Walker, Peter Kress, Nancy Orvis</p> <p align="justify">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</p> <p align="justify"> </p> <h6></h6> <h5 align="justify">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</h5> <p align="justify">Wednesday Afternoon: HIPAA privacy, meeting requests, domain, and analysis.</p> <h3 align="justify"></h3> <p align="justify">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 </p> <p align="justify">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</p> <p align="justify"><b><i>First negative ballot issue:</i></b> 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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">We should continue to have these attributes named as they currently are (id filler) and disagree with the ballot comments.</p> <p align="justify"><b><i>Disposition Ballot:</i></b></p> <p align="justify">In favor of - 9, </p> <p align="justify">Opposed - 0,</p> <p align="justify">Abstain – 5</p> <p align="justify">Addendum: A subsequent discussion with O/O committee reached the following consensus:</p> <p align="justify">· Will change our “id filler” and “id placer” back to just “id”;</p> <p align="justify">· Will add “(placer)” and “(filler id)”after the id attribute in the VISIO diagram.</p> <p align="justify">· 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</p> <p align="justify"><b><i>Second negative ballot issue</i></b>: 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.</p> <p align="justify"><b><i>Disposition Statement:</i></b> 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.</p> <p align="justify">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. </p> <p align="justify">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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Ballot:</i></b></p> <p align="justify">In favor: 11</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstain: 1</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot:</i></b></p> <p align="justify">In favor: 13</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 1</p> <p align="justify">MORNING BREAK.</p> <p align="justify">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.</p> <p align="justify">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. </p> <p align="justify"><i></i></p> <p align="justify"><i>To facilitate;</i></p> <p align="justify">Indexing and retrieve</p> <p align="justify">Organizing and Sorting</p> <p align="justify">Content Indexing</p> <p align="justify">How were the document names developed?</p> <p align="justify">From: Document names utilized at: VA hospitals, Mayo Clinic, 3M Intermountain Health Care.</p> <p align="justify"><i>Initial document names</i>: (only include narrative documents such as)</p> <p align="justify">Radiology reports</p> <p align="justify">Pathology reports</p> <p align="justify">Discharge Summaries</p> <p align="justify">Progress notes.</p> <p align="justify">Consultation notes</p> <p align="justify">Wayne: The document names will need to be exhaustive. </p> <p align="justify"><i>Axis development:</i></p> <p align="justify">The initial axis names came out of the Task Forces initial meeting. </p> <p align="justify">What makes a document name what it is?</p> <p align="justify">Axis 1</p> <ol> <li> <div align="justify">Event type focus temporal context, service </div> </li> <li> <div align="justify">.Focus, subject focus, or object of the note </div> </li> <li> <div align="justify">Temporal relationship to care. </div> </li> </ol> <p align="justify">Axis 2 </p> <p align="justify">Property - always finding</p> <p align="justify">Axis 3</p> <p align="justify">Time aspect – encounter or point in time</p> <p align="justify">Axis 4</p> <p align="justify">Practice Setting – type of environment </p> <p align="justify">Axis 5</p> <p align="justify">Kind of narrative -document</p> <p align="justify">Axis 6</p> <p align="justify">Role of documentor – in relationship to patient or family, i.e. physician.</p> <p align="justify">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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Comments on the Ballot - Issue:</i></b> Consent messages: Should this be done by the Patient Care Committee</p> <p align="justify">Act.cd values for consents: USAM questions.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> 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.</p> <p align="justify">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. </p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Ballot:</i></b></p> <p align="justify">In Favor: 15</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 0</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Comments on the Ballot –Issue Review:</i></b> Consent messages: Should this be done by the Patient Care Committee</p> <p align="justify">Act.cd values for consents: USAM questions.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> 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.</p> <p align="justify">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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Ballot:</i></b></p> <p align="justify">In Favor: 15</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 0</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Comments on the Ballot – Issue Review:</i></b> 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)</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement: </i></b>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.</p> <p align="justify">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.</p> <p align="justify">Therefore, we find these comments non-persuasive.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Ballot:</i></b></p> <p align="justify">In Favor: 7</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 8</p> <p align="justify">Tuesday Afternoon: Joint meeting between Medical Records/Health Information and Scheduling and Logistics.</p> <p align="justify"><b></b></p> <p align="justify">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. </p> <p align="justify">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.</p> <p align="justify">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)</p> <p align="justify">JWG Committee discussed next steps: JWG needs to write textual use case models (story board) for each chart request scenario.</p> <p align="justify">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.</p> <p align="justify">The committee has storyboards for the Australian and Dutch models.</p> <p align="justify"><b></b></p> <p align="justify">The JWG is in agreement; data definitions still need to be written.</p> <p align="justify">The JWG began an exercise to list all of the data definitions that need to be written.</p> <p align="justify">Data Definitions: </p> <p align="justify">· Patient Name</p> <p align="justify">· Chart defined – A chart is a group of components</p> <p align="justify">· List of Chart Components</p> <p align="justify">· Requestable Components (the part of the record to be requested)</p> <p align="justify">· Date Range – Volumes can be grouped by date. Each component will have a date.</p> <p align="justify">· Physical Volume</p> <p align="justify">· Patient ID</p> <p align="justify">· Requester Location</p> <p align="justify">· Encounter Type</p> <p align="justify">· Service Department</p> <p align="justify">· Document Type</p> <p align="justify">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. </p> <p align="justify">The committee discussed the requesting of charts by service location:</p> <p align="justify">· Radiology</p> <p align="justify">· Laboratory</p> <p align="justify">· Occupational Therapy</p> <p align="justify">· Physical Therapy</p> <p align="justify">· Speech Therapy</p> <p align="justify">· Respiratory Therapy</p> <p align="justify">Each of these service locations would have chart content listings. Which is a listing of the components that make up a service location chart.</p> <p align="justify">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.</p> <p align="justify">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?</p> <h3 align="justify">Wednesday Morning – Joint Meeting MR/IM and Structured Documents</h3> <p align="justify"><b></b></p> <p align="justify"><b><i>Ballot comment review:</i></b> 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? </p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> will move to a higher level and clarify </p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot comment review</i></b>: Records 2.1.1.2.1 page 8 “and indicates in the document management system that the findings have been authenticated by him.”</p> <p align="justify">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.”</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> Correct the grammar. Change to “finding(s) has been”</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot comment review: </i></b>2.1.1.2.1 Comment: Awkward sentence structure, not entirely sure what is the main point(s) of the sentence.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement: </i></b>agree and will correct.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot comment review:</i></b> 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. </p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> we are not sure either, so we prefer to leave is as worded.</p> <p align="justify">Original wording seems to be more prescriptive.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot comment review:</i></b> 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. </p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement</i></b>: 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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot Comment Review:</i></b> 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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> 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?</p> <p align="justify">We’ll ask the UML experts and do whatever M& M recommends here.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot:</i></b> Does anyone object to grouping the ballot comments together for a single vote.</p> <p align="justify">In Favor: 10</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 0</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot comment review:</i></b> 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).</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> Will follow the M&M recommendations.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot:</i></b></p> <p align="justify">In Favor: 10</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 0</p> <p align="justify">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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot comment review: </i></b>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)</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> See response below on our approach to CMETs. We will include the device CMET in those we submit to the CMET task group.</p> <p align="justify">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. </p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot:</i></b></p> <p align="justify">In Favor: 10</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 0</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot Comment Review:</i></b> 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) </p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> 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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot:</i></b></p> <p align="justify">In Favor: 10</p> <p align="justify">Opposed 0</p> <p align="justify">Abstained: 0</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot comment Review: </i></b>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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement</i></b>: 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.</p> <p align="justify">The value is ED, and we’ll follow M&M recommendations as to how to reflect this in the VISIO diagram.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot:</i></b></p> <p align="justify">In Favor: 10</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 0</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot comment review: </i></b>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. </p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement: </i></b>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”</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot:</i></b></p> <p align="justify"><b><i></i></b></p> <p align="justify">In Favor: 10</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 0</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot Comment Review:</i></b> 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.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Disposition Statement:</i></b> Will exclude those type _cd values that are not applicable.</p> <p align="justify">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”.</p> <p align="justify"><b><i></i></b></p> <p align="justify"><b><i>Ballot:</i></b></p> <p align="justify">In Favor: 9</p> <p align="justify">Opposed: 0</p> <p align="justify">Abstained: 0</p> <h3 align="justify"> </h3> <h3 align="justify">MORNING BREAK</h3> <p align="justify">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. </p> <p align="justify">Exclusion List:</p> <p align="justify">· Consenter, Coded as Consenter (CNS)</p> <p align="justify">· Reviewer, Coded as Reviewer (REV)</p> <p align="justify">· Witness, Coded as Witness (WIT)</p> <p align="justify">· Call Back Contact, Coded as Call Back Contact (CBC)</p> <p align="justify">· Data Entry Person, Coded as data entry person (ENT)</p> <p align="justify">· Informant, Coded as Informant (INF)</p> <p align="justify">· Tracker, Coded as Tracker</p> <p align="justify">· Escort, Coded as Escort</p> <p align="justify">· Origination Device, Coded as Origination Device (ODV)</p> <p align="justify">· Product, code as product (PRD)</p> <p align="justify">· Donor, code as donor (DON)</p> <p align="justify">· Proxy, code as proxy (NOK)</p> <p align="justify">· Patient Subject</p> <p align="justify">Leave on the list:</p> <p align="justify">· Supervisor, Coded as Supervisor (SPV)</p> <p align="justify">· Verifier, Coded as Verifier (VRF)</p> <p align="justify">· Consultant, Coded as Consultant (CON) – this should be a function code and nor a type code.</p> <p align="justify">· Referrer</p> <p align="justify">· Receiver, Code as Receiver (RCV)</p> <p align="justify">· Baby , Code as Baby (BBY)</p> <p align="justify">· Mother, Code as Mother (MTH)</p> <p align="justify">· Service Actor, </p> <p align="justify">Wednesday Afternoon: HIPAA privacy, meeting requests, domain, and analysis.</p> <p align="justify">Agenda for the HL7 Medical Record/information Management Technical Committee Meeting in San Diego, CA, January 8 & 9, 2002</p> <p align="justify"><b></b></p> <p align="justify"><b>Agenda Items:</b></p> <p align="justify"><b></b></p> <p align="justify"><b>Tuesday AM:</b></p> <p align="justify"><b></b></p> <p align="justify"><b>Joint Work Group meeting MR/IM TC and Structured Documents. </b>V3 Ballot 2 preparation.</p> <p align="justify"><b></b></p> <p align="justify"><b>Tuesday PM:</b></p> <p align="justify"><b></b></p> <p align="justify"><b>Joint meeting between Medical Records/Health Information and Scheduling and Logistics. </b>Advance work in chart tracking model, develop story boards and data definition.<b> </b></p> <p align="justify"><b></b></p> <p align="justify"><b>Wednesday AM:</b></p> <p align="justify"><b></b></p> <p align="justify"><b>Joint Work Group meeting MR/IM TC and Structured Documents. </b>V3 Ballot 2 preparation.</p> <p align="justify"><b></b></p> <p align="justify"><b></b></p> <p align="justify"><b>Wednesday PM:</b></p> <p align="justify"><b></b></p> <p align="justify"><b>Joint meeting between Medical Records/Health Information and Scheduling and Logistics.</b> Advance work in chart tracking model, develop story board and data definitions.</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-56618733225993995342011-08-28T05:03:00.001-07:002011-08-28T05:03:29.716-07:00National Standards for the structure and content of medical records.<h3 align="center">National Standards for the structure and content of medical records.</h3> <h3 align="center">The Medical Record Keeping Standards Programme of the Health Informatics Unit at the Royal College of Physicians, London.</h3> <p align="center"> </p> <p align="center"> </p> <p align="left"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> <p align="justify">Prof. Iain Carpenter, Health Informatics Unit, Royal College of Physicians, London/Centre for Health Service Studies, University of Kent, Canterbury</p> <p align="justify">Mala Bridgelal Ram, Health Informatics Unit, Royal College of Physicians, London</p> <p align="justify">Professor John Williams, Director, Health Informatics Unit, Royal College of Physicians, London/ School of Medicine, Swansea University</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">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<a href="#_ftn1_4816" name="_ftnref1_4816">[1]</a>.</p> <p align="justify">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).</p> <p align="justify">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. </p> <p align="justify">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. </p> <p align="justify">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.</p> <p align="justify">On April 17<sup>th</sup> 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.</p> <p align="justify">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.</p> <p align="justify">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.</p> <p align="justify">The NHS Digital and Health Information Policy Directorate has published a two part clinician’s guide to the standards.</p> <p align="justify">v <b>Part 1 </b>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.</p> <p align="justify">v <b>Part 2 </b>contains the Generic Medical Record Keeping Standards and the structure and content standards for admission, handover and discharge documents<b>.</b></p> <p align="justify">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 </p> <div align="justify"> <hr align="left" width="33%" size="1" /></div> <p align="justify">[1] Carpenter, Iain; Bridgelal Ram, Mala; Croft, Giles P; Williams, John G, 2007. Medical records and record-keeping standards. <i>Clinical Medicine</i>: 7(4):328-331</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-12743141705092088822011-08-28T05:01:00.001-07:002011-08-28T05:01:12.558-07:00Medical Record Release<h1>Medical Record Release<b style="mso-bidi-font-weight: normal"><i style="mso-bidi-font-style: normal"> <p></p> </i></b></h1> <p class="MsoNormal" style="text-align: center" align="center"><b style="mso-bidi-font-weight: normal"><span style="font-size: 11pt; mso-bidi-font-size: 10.0pt"> <p> </p> </span></b></p> <h2>Patient Information <span style="font-weight: normal; font-size: 8pt; mso-bidi-font-weight: bold; mso-bidi-font-size: 10.0pt">(please print) <p></p> </span></h2> <p class="form" style="margin-right: 0cm">Patient Name:<span style="mso-tab-count: 1">   </span>____________________________<span style="mso-tab-count: 1">    </span>Date of Birth: <span style="mso-tab-count: 1">   </span>________________________<span style="mso-tab-count: 1">  </span> <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 495.0pt">Address:<span style="mso-tab-count: 1">        </span>______________________________________________________________________<span style="mso-tab-count: 1">  </span> <p></p> </p> <p class="form" style="margin-right: 0cm">Telephone #: <span style="mso-tab-count: 1">    </span>____________________________<span style="mso-tab-count: 1">    </span>Medical Record #: <span style="mso-tab-count: 1">  </span>_____________________ <p></p> </p> <h2> <p> </p> </h2> <h2>Release Information to <p></p> </h2> <p class="form" style="margin-right: 0cm; tab-stops: right 495.0pt">Name/Facility:<span style="mso-tab-count: 1">       </span>__________________________________________________________________ <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 495.0pt">Address: <span style="mso-tab-count: 1">       </span>______________________________________________________________________ <p></p> </p> <p class="form" style="margin-right: 0cm"><span style="mso-tab-count: 1">                                                                   </span> <p></p> </p> <h2>Information to be Released <span style="font-weight: normal; font-size: 8pt; mso-bidi-font-size: 10.0pt">(check all that apply)</span><span style="font-weight: normal; font-size: 8pt; font-family: "Wingdings 2"; mso-bidi-font-size: 10.0pt"> <p></p> </span></h2> <p class="form" style="margin-right: 0cm; tab-stops: 13.5pt 144.0pt 157.5pt 288.0pt 301.5pt right 495.0pt"><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Clinic Visit Notes<span style="mso-tab-count: 1">             </span><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Imaging Reports<span style="font-family: "Wingdings 2""> <span style="mso-tab-count: 1">    </span>*<span style="mso-tab-count: 1"> </span></span>Pathology Reports <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: 13.5pt 144.0pt 157.5pt 288.0pt 301.5pt right 495.0pt"><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Complete Chart<span style="font-family: "Wingdings 2""> <span style="mso-tab-count: 1">    </span>*<span style="mso-tab-count: 1"> </span></span>Lab Reports<span style="font-family: "Wingdings 2""> <span style="mso-tab-count: 1">      </span>*<span style="mso-tab-count: 1"> </span></span>Other:<span style="mso-tab-count: 1">   </span>_________________________<span style="mso-tab-count: 1">  </span> <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: 13.5pt 144.0pt 157.5pt 288.0pt 301.5pt right 495.0pt"><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Discharge Summary<span style="mso-tab-count: 1">        </span><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Operative Reports<span style="mso-tab-count: 3">                          </span>_________________________ <p></p> </p> <h2><span style="font-weight: normal"> <p> </p> </span></h2> <h2><span style="mso-bidi-font-weight: bold">Authorization</span><span style="font-weight: normal"> </span><span style="font-weight: normal; font-size: 9pt; mso-bidi-font-weight: bold; mso-bidi-font-size: 10.0pt">(<span style="mso-bidi-font-style: italic">authorization</span> remains valid for 90 days from date of signature) <p></p> </span></h2> <p class="form" style="margin-right: 0cm; tab-stops: right 342.0pt left 360.0pt right 495.0pt">Patient Signature:<span style="mso-tab-count: 1">     </span>_______________________________________<span style="mso-tab-count: 1">     </span>Date: <span style="mso-tab-count: 1">  </span>________________ <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 342.0pt left 360.0pt right 495.0pt">Parent/Guardian:<span style="mso-tab-count: 1">      </span>_______________________________________<span style="mso-tab-count: 1">     </span>Date:<span style="mso-tab-count: 1">   </span>________________ <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 342.0pt left 360.0pt right 495.0pt"> <p> </p> </p> <h2> <p> </p> </h2> <div style="border-right: medium none; padding-right: 0cm; border-top: gray 1pt solid; padding-left: 0cm; padding-bottom: 0cm; border-left: medium none; padding-top: 1pt; border-bottom: medium none; mso-element: para-border-div; mso-border-top-alt: solid gray .5pt"> <h2 style="border-right: medium none; padding-right: 0cm; border-top: medium none; padding-left: 0cm; padding-bottom: 0cm; border-left: medium none; padding-top: 0cm; border-bottom: medium none; mso-padding-alt: 1.0pt 0cm 0cm 0cm; mso-border-top-alt: solid gray .5pt">Authorization for Release of Sensitive Information <p></p> </h2> </div> <p class="body" style="margin-right: 0cm">This medical record may contain certain sensitive or statutorily protected information. <br />Please indicate the information you would like released. A separate signature is required. <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: 13.5pt 243.0pt 256.5pt right 495.0pt"><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Mental Health Information<span style="mso-tab-count: 1">                           </span><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Social Service Information <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: 13.5pt 243.0pt 256.5pt right 495.0pt"><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Domestic Violence Information<span style="mso-tab-count: 1">                     </span><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Sexual Assault Information <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: 13.5pt 243.0pt 256.5pt right 495.0pt"><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Alcohol/Drug Abuse Information<span style="mso-tab-count: 1">                   </span><span style="font-family: "Wingdings 2"">*<span style="mso-tab-count: 1"> </span></span>Sexually Transmitted Diseases <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 342.0pt left 360.0pt right 495.0pt">Patient Signature:<span style="mso-tab-count: 1">     </span>_______________________________________<span style="mso-tab-count: 1">     </span>Date: <span style="mso-tab-count: 1">  </span>________________ <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 342.0pt left 360.0pt right 495.0pt">Parent/Guardian:<span style="mso-tab-count: 1">      </span>_______________________________________<span style="mso-tab-count: 1">     </span>Date:<span style="mso-tab-count: 1">   </span>________________<span style="mso-tab-count: 1">  </span> <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 342.0pt left 360.0pt right 495.0pt"> <p> </p> </p> <p class="form" style="margin-right: 0cm"> <p> </p> </p> <div style="border-right: medium none; padding-right: 0cm; border-top: gray 1pt solid; padding-left: 0cm; padding-bottom: 0cm; border-left: medium none; padding-top: 1pt; border-bottom: medium none; mso-element: para-border-div; mso-border-top-alt: solid gray .5pt"> <h2 style="border-right: medium none; padding-right: 0cm; border-top: medium none; padding-left: 0cm; padding-bottom: 0cm; border-left: medium none; padding-top: 0cm; border-bottom: medium none; mso-padding-alt: 1.0pt 0cm 0cm 0cm; mso-border-top-alt: solid gray .5pt">HIV Testing and AIDS Treatment <p></p> </h2> </div> <p class="body" style="margin-right: 0cm">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 <b><i>single release</i></b> only. <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 342.0pt left 360.0pt right 495.0pt">Patient Signature:<span style="mso-tab-count: 1">     </span>_______________________________________<span style="mso-tab-count: 1">     </span>Date: <span style="mso-tab-count: 1">  </span>________________ <p></p> </p> <p class="form" style="margin-right: 0cm; tab-stops: right 342.0pt left 360.0pt right 495.0pt">Parent/Guardian:<span style="mso-tab-count: 1">      </span>_______________________________________<span style="mso-tab-count: 1">     </span>Date:<span style="mso-tab-count: 1">   </span>________________<span style="mso-tab-count: 1">  </span></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-86165317065974905862011-08-28T04:59:00.001-07:002011-08-28T04:59:21.241-07:00Deployed Medical Record Request Instructions<div align="justify"> <table cellpadding="0" border="0"><tbody> <tr> <td width="99%"> <p align="center">Deployed Medical Record Request Instructions</p> </td> </tr> <tr> <td width="99%"> <p align="center"><b>DD 2870</b><b> - Authorization for disclosure of medical or dental information, Dec. 2003</b></p> </td> </tr> <tr> <td width="99%"> <p align="center">In order to facilitate the release of medical records, PASBA will follow this procedure:</p> </td> </tr> <tr> <td width="99%"> <p><b>Requesting a copy of the medical record</b></p> </td> </tr> <tr> <td width="99%"> <ol> <li>PASBA will first verify if the medical record is in their possession. </li> <li>If the record is in PASBA's custody, the requestor must complete DD Form 2870 (Authorization for Disclosure of Medical or Dental Information) and have the Service Member sign the form authorizing release of medical information. The requestor must provide detailed information describing specifically what information is being requested and why that information is needed, (i.e. UCMJ, Medical Board Processing, Separation Processing), particularly if the Service Member refuses to sign the request. <br />In addition, specify exactly what episode of care the request is for. </li> <li>Once PASBA receives the signed authorization form, the PASBA Information Assurance (IA) Coordinator will review and verify the authenticity of the request and identity of the requestor as the patient owner of the record. After all requirements are fulfilled, the IA coordinator will approve to copy the record. PASBA will duplicate the medical record and mail the duplicate to the Service Member. A copy of DD Form 2870 will be placed in the Service Member's medical record documenting this action. </li> <li>The Requestor may be directed to contact NPRC in the event that the Medical Record has been retired. The Requestor may also be directed to the military treatment facility they were seen at in theater if PASBA has no record of receiving the medical record. </li> <li>Ft. Sam Houston SJA will review all medical records request from outside entities. Once SJA has approved this request, PASBA will duplicate the medical record and mail the duplicate to the requesting party. A copy of DD Form 2870 will be placed in the Service Member's medical record documenting this action. </li> </ol> </td> </tr> <tr> <td width="99%"> <p><b>Purpose</b></p> </td> </tr> <tr> <td width="99%"> <p>PASBA receives all Inpatient Records from deployed medical units that do not have access to the Composite Health Care System (CHCS) once that unit returns from theater. PASBA reviews, performs data quality checks, codes, enters the record information into a number of databases and then forwards them to the National Personnel Records Center (NPRC) in St. Louis, Missouri for retirement. </p> </td> </tr> <tr> <td width="99%"> <p><b>AR 40-66</b></p> </td> </tr> <tr> <td width="99%"> <p>Army Regulation 40-66, Chapter 2 explains DA policies and procedures governing the release of medical information or medical records pertaining to individual patients. DA policy mandates that the confidentiality of patient medical information and medical records be protected to the fullest extent. </p> </td> </tr> <tr> <td width="99%"> <p><b>Procedure</b></p> </td> </tr> <tr> <td width="99%"> <p>There may be instances when the patient or other agency (Staff Judge Advocate (SJA) Officer, soldier's Commander, MTF's Case Worker, etc.) requires copies of the medical records from deployments. Because the inpatient record is only at PASBA for a short time, there is a possibility the record may not be at PASBA when the request is made. PASBA will follow the above stated procedure (Requesting a copy of the medical record).</p> </td> </tr> <tr> <td width="99%"> <p><b>For requests, problems, or assistance contact:</b></p> </td> </tr> <tr> <td width="99%"> <p>Information Assurance Coordinator, (210) 221-1414 DSN: 471 <br />E-Mail Address: <b>Record.Request@pasba2.amedd.army.mil</b> <br />Fax Num. 221-0263 DSN 471 </p> <p>To suggest corrective action, Deputy Director, PASBA, (210) 295-9507 DSN: 421 <br />E-Mail Address: <b>Record.Request@pasba2.amedd.army.mil</b> <br />Fax Num. 221-0579 DSN 471 </p> </td> </tr> </tbody></table> </div> <div align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></div> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-45766887335446084252011-08-28T04:54:00.001-07:002011-08-28T04:54:23.624-07:00HOW PRIVATE IS MY MEDICAL INFORMATION?<p align="justify">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.</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> <p align="justify"> </p> <p align="justify"><b>What do my medical records contain?</b></p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b>Who has access to my medical records?</b></p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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).</p> <p align="justify"> </p> <p align="justify">2. Government agencies may request your medical records to verify claims made through Medicare, MediCal, Social Security Disability and Workers Compensation.</p> <p align="justify"> </p> <p align="justify">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 <a href="http://www.mib.com">www.mib.com</a></p> <p align="justify"> </p> <p align="justify">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:</p> <p align="justify">Medical Information Bureau <br />P.O. Box 105, Essex Station <br />Boston, MA 02112 <br />or call (617) 426-3660.</p> <p align="justify">4. Employers usually obtain medical information about their employees by asking employees to authorize disclosure of medical records. This can occur in several ways.</p> <ul> <ul> <ul> <li> <div align="justify">When medical insurance is paid by employers, they may require insurance companies to provide them with copies of employees' medical records.</div> </li> <li> <div align="justify">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.</div> </li> </ul> </ul> </ul> <p align="justify">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.)</p> <p align="justify">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</p> <ul> <ul> <ul> <li> <div align="justify">Employers may not ask job applicants about medical information or require a physical examination prior to offering employment.</div> </li> <li> <div align="justify">After employment is offered, an employer can only ask for a medical examination if it is required of all employees holding similar jobs.</div> </li> <li> <div align="justify">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.</div> </li> </ul> </ul> </ul> <p align="justify">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. <br />Web: <a href="http://www.eeoc.gov/laws/ada.html">www.eeoc.gov/laws/ada.html</a></p> <p align="justify"> </p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b>Is there any way to protect the privacy of my medical records?</b></p> <p align="justify">Currently, there are <i>no</i> comprehensive laws regarding medical records privacy. Here are some methods which may limit others' access to your medical records:</p> <p align="justify">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.</p> <ul> <ul> <ul> <li> <div align="justify"><i>Example of blanket waiver</i>: 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.</div> </li> <li> <div align="justify"><i>Edited waiver:</i> I authorize my records to be released from [X hospital, clinic or doctor] for the [date of treatment] as relates to [the condition treated].</div> </li> <li> <div align="justify"> </div> </li> </ul> </ul> </ul> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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.")</p> <p align="justify">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.")</p> <p align="justify"> </p> <p align="justify"><b>How do I get access to my own medical records?</b></p> <p align="justify">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).</p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify"><b>The future of medical records privacy</b></p> <p align="justify">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.</p> <p align="justify"> </p> <p align="justify">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. <i>If you have an opinion or concern, contact your state and federal legislators</i>.</p> <p align="justify"> </p> <p align="justify"><b>For more information</b></p> <p align="justify">A leader in fighting for patients’ privacy rights is the National Coalition for Patient Rights <br />405 Waltham St., Suite 218 <br />Lexington, MA 02173 <br />Phone: (781) 861-0635 <br />Web: www.nationalcpr.org</p> <p align="justify">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. <br />Contact AHIMA at 919 N. Michigan Ave. <br />Chicago IL 60611-1683. <br />Phone: (800) 335-5535.</p> <p align="justify">For help with the Americans with Disabilities Act, call the nearest Technical Assistance Center, (800) 949-4232. <br />Web: www.pacdbtac.org or www.adata.org</p> <p align="justify">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. <br />Phone: (202) 690-5896. <br />Web: www.dhhs.gov</p> <p align="justify">The Health Privacy Project of Georgetown University is a resource for public policy information, especially federally-mandated privacy protection due by August 21, 1999. <br />Web: www.healthprivacy.org <br />The Web site includes information on federal privacy legislation.</p> <p align="justify">For health privacy-related disputes in California, contact the county medical society or the Medical Board of California at (800) 633-2322. <br />Web: www.medbd.ca.gov</p> <p align="justify">For information about access to health records, visit the Web site of the California Medical Association, www.cmanet.org (look for "Free Legal Information").</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-3706607830063581792011-08-28T04:50:00.001-07:002011-08-28T04:50:21.053-07:00Medical Record Abstraction Form<span style="z-index: 251657728; position: relative; mso-ignore: vglayout"> <p class="MsoFooter" style="margin-bottom: 6pt; tab-stops: 36.0pt"> </p> <p class="MsoFooter" style="margin-bottom: 6pt; tab-stops: 36.0pt"> </p> <table cellspacing="0" cellpadding="0"><tbody> <tr> <td width="528"></td> </tr> <tr> <td></td> <td width="136"> <table cellspacing="0" cellpadding="0"><tbody> <tr> <td> <p>ID _________</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p class="MsoFooter" style="margin-bottom: 6pt; tab-stops: 36.0pt"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> <p class="MsoFooter" style="margin-bottom: 6pt; tab-stops: 36.0pt"></p> </span> <p class="MsoFooter" style="margin-bottom: 6pt; tab-stops: 36.0pt"><b><span style="font-family: "Arial","sans-serif"">Instructions</span></b><b><span style="font-size: 11pt; font-family: "Arial","sans-serif"">: </span></b><span style="font-family: "Arial","sans-serif"; mso-bidi-font-weight: bold">Please </span><span style="font-family: "Arial","sans-serif"">review the <u>infant</u> and <u>maternal</u> medical records</span><b><span style="font-size: 11pt; font-family: "Arial","sans-serif""> <p></p> </span></b></p> <p class="MsoFooter" style="margin-bottom: 6pt; tab-stops: 36.0pt"><b style="mso-bidi-font-weight: normal"><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Please review the <u>maternal</u> medical record for questions 1-15: <p></p> </span></b></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">1.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">What is the mother’s month and year of birth? <span style="mso-spacerun: yes">  </span>___/_________ <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">2.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">What is the ethnicity of the mother? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 54pt; tab-stops: 36.0pt"><span style="mso-bookmark: check5"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check5"></a></span></span><span style="mso-bookmark: check5"></span><span style="mso-bookmark: check5"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Hispanic or Latino <span style="mso-tab-count: 2">                   </span></span><span style="mso-bookmark: check6"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check6"></a></span></span><span style="mso-bookmark: check6"></span><span style="mso-bookmark: check6"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Not Hispanic or Latino<span style="mso-tab-count: 1">       </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>unknown <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">3.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">What is the race of the mother? Please check all that apply. <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 54pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>White </span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>African American<span style="mso-spacerun: yes">  </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Asian<span style="mso-spacerun: yes">  </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>American Indian or <place w:st="on"><state w:st="on">Alaska</state></place> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 54pt; tab-stops: 36.0pt"><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Native </span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Native Hawaiian or Other Pacific Islander </span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Other or unknown <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">4.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Mother’s Insurance Status? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 54pt; tab-stops: 36.0pt"><span style="mso-bookmark: check11"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check11"></a></span></span><span style="mso-bookmark: check11"></span><span style="mso-bookmark: check11"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Private </span><span style="mso-bookmark: check12"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check12"></a></span></span><span style="mso-bookmark: check12"></span><span style="mso-bookmark: check12"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Medicaid </span><span style="mso-bookmark: check13"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check13"></a></span></span><span style="mso-bookmark: check13"></span><span style="mso-bookmark: check13"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Other or Unknown <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">5.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Please indicate admission date ___/___/_____<span style="mso-spacerun: yes">  </span>and time ___:___ am/pm <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 18pt; tab-stops: 36.0pt"><span style="font-size: 5pt; font-family: "Arial","sans-serif""> <p> </p> </span></p> <div style="border-right: windowtext 1pt solid; padding-right: 4pt; border-top: windowtext 1pt solid; padding-left: 4pt; padding-bottom: 1pt; margin-left: 18pt; border-left: windowtext 1pt solid; margin-right: 0cm; padding-top: 1pt; border-bottom: windowtext 1pt solid; mso-element: para-border-div; mso-border-alt: solid windowtext .5pt"> <p class="MsoFooter" style="border-right: medium none; padding-right: 0cm; border-top: medium none; padding-left: 0cm; margin-bottom: 6pt; padding-bottom: 0cm; border-left: medium none; padding-top: 0cm; border-bottom: medium none; tab-stops: 36.0pt; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 1.0pt 4.0pt 1.0pt 4.0pt"><b style="mso-bidi-font-weight: normal"><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Prenatal Care <p></p> </span></b></p> </div> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">6.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was there a prenatal HBsAg (hepatitis B surface antigen) test performed <b style="mso-bidi-font-weight: normal">prior to admission</b>? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; tab-stops: 36.0pt"><span style="mso-bookmark: check14"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check14"></a></span></span><span style="mso-bookmark: check14"></span><span style="mso-bookmark: check14"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes <span style="mso-tab-count: 1">            </span></span><span style="mso-bookmark: check15"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check15"></a></span></span><span style="mso-bookmark: check15"></span><span style="mso-bookmark: check15"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 2">              </span><span style="mso-tab-count: 1">            </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">7.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">What was the prenatal HBsAg test date? ___/___/_____<span style="mso-spacerun: yes">  </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Not documented <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">8.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">What was the prenatal HBsAg test result? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 54pt; tab-stops: 36.0pt"><span style="mso-bookmark: check17"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check17"></a></span></span><span style="mso-bookmark: check17"></span><span style="mso-bookmark: check17"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Positive </span><span style="mso-bookmark: check18"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check18"></a></span></span><span style="mso-bookmark: check18"></span><span style="mso-bookmark: check18"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Negative </span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Not documented<span style="mso-tab-count: 1">      </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">9.<span style="font: 7pt "Times New Roman"">    </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">How was HBsAg status of mother documented? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 54pt; tab-stops: 36.0pt"><span style="mso-bookmark: check23"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check23"></a></span></span><span style="mso-bookmark: check23"></span><span style="mso-bookmark: check23"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Copy of laboratory report <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 54pt; tab-stops: 36.0pt"><span style="mso-bookmark: check24"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check24"></a></span></span><span style="mso-bookmark: check24"></span><span style="mso-bookmark: check24"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Clinician transcription of information into medical record from other source <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 54pt; tab-stops: 36.0pt"><span style="mso-bookmark: check25"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check25"></a></span></span><span style="mso-bookmark: check25"></span><span style="mso-bookmark: check25"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Other, describe: _____________________________________ <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">10.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was there an HIV test performed <b style="mso-bidi-font-weight: normal">prior to admission</b>? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes <span style="mso-tab-count: 1">            </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 2">              </span><span style="mso-tab-count: 2">                       </span><span style="mso-spacerun: yes"> </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">11.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">What was the prenatal HIV test date? ____/___/____ </span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Not documented <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 18pt; text-align: center; tab-stops: 36.0pt" align="center"><i style="mso-bidi-font-style: normal"><span style="font-size: 11pt; background: yellow; font-family: "Arial","sans-serif"; mso-highlight: yellow">Consider adding additional questions on syphilis, GBS, etc.</span></i><i style="mso-bidi-font-style: normal"><span style="font-size: 11pt; font-family: "Arial","sans-serif""> <p></p> </span></i></p> <div style="border-right: windowtext 1pt solid; padding-right: 4pt; border-top: windowtext 1pt solid; padding-left: 4pt; padding-bottom: 1pt; margin-left: 18pt; border-left: windowtext 1pt solid; margin-right: 0cm; padding-top: 1pt; border-bottom: windowtext 1pt solid; mso-element: para-border-div; mso-border-alt: solid windowtext .5pt"> <p class="MsoFooter" style="border-right: medium none; padding-right: 0cm; border-top: medium none; padding-left: 0cm; margin-bottom: 6pt; padding-bottom: 0cm; border-left: medium none; padding-top: 0cm; border-bottom: medium none; tab-stops: 36.0pt; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 1.0pt 4.0pt 1.0pt 4.0pt"><b style="mso-bidi-font-weight: normal"><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Admission to Labor and Delivery <p></p> </span></b></p> </div> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">12.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was there an HBsAg test performed <b style="mso-bidi-font-weight: normal">during the hospital stay</b>? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes <span style="mso-tab-count: 1">            </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 2">              </span><span style="mso-tab-count: 2">                        </span><span style="mso-tab-count: 1">            </span></span><span style="font-size: 8pt; font-family: "Arial","sans-serif"; mso-bidi-font-size: 11.0pt"> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">13.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">What was the result of the HBsAg test performed <b style="mso-bidi-font-weight: normal">during the hospital stay</b>? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 18pt; text-indent: 18pt; tab-stops: 36.0pt"><span style="mso-bookmark: check20"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check20"></a></span></span><span style="mso-bookmark: check20"></span><span style="mso-bookmark: check20"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Positive <span style="mso-tab-count: 1">     </span></span><span style="mso-bookmark: check21"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check21"></a></span></span><span style="mso-bookmark: check21"></span><span style="mso-bookmark: check21"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Negative <span style="mso-tab-count: 1">   </span></span><span style="mso-bookmark: check22"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check22"></a></span></span><span style="mso-bookmark: check22"></span><span style="mso-bookmark: check22"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Not documented <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">14.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was there an HIV test performed <b style="mso-bidi-font-weight: normal">during the hospital stay</b>? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes <span style="mso-tab-count: 1">            </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 2">              </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">15.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Type of attending provider <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; tab-stops: 36.0pt"><span style="mso-bookmark: check26"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check26"></a></span></span><span style="mso-bookmark: check26"></span><span style="mso-bookmark: check26"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Obstetrician </span><span style="mso-bookmark: check27"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check27"></a></span></span><span style="mso-bookmark: check27"></span><span style="mso-bookmark: check27"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Family practitioner </span><span style="mso-bookmark: check28"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check28"></a></span></span><span style="mso-bookmark: check28"></span><span style="mso-bookmark: check28"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Other or unknown <p></p> </span></p> <span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: 'Times New Roman'; mso-ansi-language: en-us; mso-fareast-language: en-us; mso-bidi-language: ar-sa"> <br style="page-break-before: always" clear="all" /></span> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -36pt; tab-stops: 36.0pt"><b><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Please review <u>neonatal</u> medical record for Questions 16-29: <p></p> </span></b></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">16.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Please indicate infant’s date of delivery ___/___/_____<span style="mso-spacerun: yes">  </span>and time of delivery ___:___ am/pm <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">17.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Did the infant weigh <2,000 grams at birth? <p></p> </span></p> <p class="MsoNormal" style="text-indent: 36pt"><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-tab-count: 1">            </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 3">                         </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 1">  </span><span style="mso-tab-count: 2">                        </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">18.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Is there a recorded maternal HIV test result? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: 36pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 3">                         </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 2">              </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">19.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Is there a recorded maternal HBsAg test result? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 72pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 3">                         </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 1">  </span><span style="mso-tab-count: 2">                        </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">20.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">What was the maternal HBsAg test result? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 108pt; text-indent: -36pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Positive <span style="mso-tab-count: 2">                 </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Negative <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">21.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was HBIG (hepatitis B immune globulin) given to the infant? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 72pt; tab-stops: 36.0pt"><span style="mso-bookmark: check29"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check29"></a></span></span><span style="mso-bookmark: check29"></span><span style="mso-bookmark: check29"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes; date ___/___/_____<span style="mso-tab-count: 1">   </span>Time ___:___ am/pm <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 108pt; text-indent: -36pt; tab-stops: 36.0pt"><span style="mso-bookmark: check30"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"><a name="Check30"></a></span></span><span style="mso-bookmark: check30"></span><span style="mso-bookmark: check30"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">22.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was infant HBIG administered as a result of hospital pre-printed admission orders*? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: 18pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 2">                   </span><span style="mso-tab-count: 1">            </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 1">  </span><span style="mso-tab-count: 2">                        </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">23.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">If there were no hospital pre-printed admission orders*, was infant HBIG administered as a result of a specific physician order? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: 18pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 3">                               </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 1">  </span><span style="mso-tab-count: 2">                        </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">24.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was hepatitis B vaccine given to the infant? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: 18pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 3">                               </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 1">  </span><span style="mso-tab-count: 1">            </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">25.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Please indicate date of hepatitis B vaccine<span style="mso-spacerun: yes">  </span>___/___/_____<span style="mso-spacerun: yes">  </span>and time of<span style="mso-spacerun: yes">  </span>administration ___:___ am/pm <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">26.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was hepatitis B vaccine administered as a result of hospital pre-printed admission orders*? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: 18pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 2">                   </span><span style="mso-tab-count: 1">            </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 1">  </span><span style="mso-tab-count: 2">                        </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">27.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">If there were no hospital pre-printed admission orders*, was hepatitis B vaccine administered as a result of a specific physician order? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: 18pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 3">                               </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No<span style="mso-tab-count: 1">  </span><span style="mso-tab-count: 2">                        </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">28.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">Was there any specific order in the neonatal medical record <b style="mso-bidi-font-weight: normal"><i style="mso-bidi-font-style: normal">not </i></b>to vaccinate against hepatitis B virus? <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: 18pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Yes<span style="mso-tab-count: 1">       </span><span style="mso-tab-count: 1">            </span><span style="mso-tab-count: 1">            </span></span><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No; end survey<span style="mso-tab-count: 1">      </span> <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-indent: -18pt; tab-stops: list 36.0pt; mso-list: l0 level1 lfo1"><span style="font-size: 11pt; font-family: "Arial","sans-serif"; mso-fareast-font-family: arial"><span style="mso-list: ignore">29.<span style="font: 7pt "Times New Roman"">  </span></span></span><span style="font-size: 11pt; font-family: "Arial","sans-serif"">If there was an order <b style="mso-bidi-font-weight: normal"><i style="mso-bidi-font-style: normal">not </i></b>to vaccinate, what was documented as the reason for not vaccinating? Please check all that apply. <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 72pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Infant was <2,000 grams at birth <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 72pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Infant was not medically stable <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 72pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Mother was HBsAg negative <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 72pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Guardian refused <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 72pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>No reason documented <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 72pt; tab-stops: 36.0pt"><span style="font-size: 11pt; background: silver; font-family: "Arial","sans-serif"; mso-highlight: silver"></span><span style="font-size: 11pt; font-family: "Arial","sans-serif""><span style="mso-spacerun: yes"> </span>Other reason; please specify below: <p></p> </span></p> <p class="MsoFooter" style="margin: 0cm 0cm 6pt 36pt; text-align: center; tab-stops: 36.0pt" align="center"><b style="mso-bidi-font-weight: normal"><span style="font-size: 12pt; font-family: "Arial","sans-serif"">Thank you for your participation! <p></p> </span></b></p> <p></p> <p><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-45784700437964619752011-08-28T04:45:00.001-07:002011-08-28T04:45:13.611-07:00PROBLEM ORIENTED MEDICAL RECORD (POMR)<p align="justify">Penyelenggaraan sistem rekam medis pada institusi pelayanan kesehatan sangat variatif mulai dari yang sangat sederhana hingga yang sangat canggih dan kompleks. Salah satu model sistem rekam medis yang ada adalah POMR (problem Oriented Medicai Record) yang diprakarsai oleh Dr. Lawrence L. Weed (the father of POMR).</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> <p align="justify"> </p> <p align="justify">Dr. Lawrence L. Weed mengemukakan “Weed System” yang menjadi inti dari Problem Oriented Medical record yaitu:</p> <p align="justify">o Mendefinisikan database</p> <p align="justify">o Menyusun daftar masalah</p> <p align="justify">o Membuat catatan yang berorientasi pada daftar masalah</p> <p align="justify">Secara sederhana teori mengenai Problem Oriented Medical record ini digambarkan dalam “The Four Boxes of Dr. Weed”:</p> <p align="justify"> <table cellspacing="0" cellpadding="0"><tbody> <tr> <td width="35"></td> </tr> <tr> <td></td> <td><a href="http://lh3.ggpht.com/-hLgjs6oGgqk/TloqFoUeTCI/AAAAAAAABMI/8rxOnAIEvCQ/s1600-h/1%25255B6%25255D.png"><img title="1" style="border-right: 0px; border-top: 0px; display: block; float: none; margin-left: auto; border-left: 0px; margin-right: auto; border-bottom: 0px" height="163" alt="1" src="http://lh3.ggpht.com/-hZBkiBlQebo/TloqOjqGL8I/AAAAAAAABMM/IK24I2wdj0k/1_thumb%25255B10%25255D.png?imgmax=800" width="244" border="0" /></a> </td> </tr> </tbody></table> </p> <p align="justify">Dari bagan di atas dapat dilihat bahwa Problem Oriented Medical Record terdiri dari 4 bagian utama yaitu databases(basis data), problem list(daftar masalah), plans(perencanaan) dan progress note(catatan kemajuan).</p> <p align="justify">Database atau basis data adalah kumpulan segala informasi pasien yang berobat ke institusi pelayanan kesehatan. Informasi atau data mengenai pasien tersebut dapat dikategorikan menjadi 2, yaitu:</p> <p align="justify"> </p> <p align="justify">o Data Sosial</p> <p align="justify">Terutama terdiri atas identitas soaial pasien seperti nama, tanggal lahir, jenis kelamin, alamat, pendidikan, status perkawinan, dll.</p> <p align="justify"> </p> <p align="justify">o Data Medis</p> <p align="justify">Terutama terdiri dari riwayat medis pasien, catatan pemeriksaan fisik, hasil lab, dll.</p> <p align="justify">Problem list atau daftar masalah adalah dasar acuan dari rekam medis yang berorientasi pada masalah. ”Problem list” bukan merupakan komposisi yang bersifat statis atau tetap melainkan suatu ”table of contents” yang dinamis dari grafik pasien yang dapat di-update setiap saat. Ketelitian mengenai jenis masalah, catatan kemajuan yang berorientasi masalah dan kesimpulannya secara langsung berhubungan dengan ketelitian dan integritas dimana masalah pertamakali diidentifikasikan. Tidak pernah ada kata benar atau salah dalam keputusan sepihak mengenai kasus yang sulit, yang ada hanyalah keputusan yang ilmiah dan logis atau tidak ilmiah dan tidak logis yang dikeluarkan dengan hati-hati atau tidak hati-hati(Weed, 1968).</p> <p align="justify"> </p> <p align="justify">Problem List antara lain mengacu pada masalah:</p> <p align="justify">o medical (biological)</p> <p align="justify">o psychiatric</p> <p align="justify">o social </p> <p align="justify">o demographic</p> <p align="justify">o diagnosis</p> <p align="justify">o physiologic finding</p> <p align="justify">o symptom</p> <p align="justify">o physical finding</p> <p align="justify">o lab abnormality</p> <p align="justify">o social issue</p> <p align="justify">o demographic issue</p> <p align="justify"> </p> <p align="justify">Plans atau perencanaan dibuat saat pertama kali pasien yang bersangkutan berobat ke institusi pelayanan kesehatan terkait. Dari data pasien dan daftar masalah yang sudah diidentifikasi dapat dibuat suatu perencanaan, pada umumnya perencanaan ini terdiri dari:</p> <p align="justify">o Diagnostic</p> <p align="justify">Perencanaan mengenai studi lebih mendalam tentang diagnosis.</p> <p align="justify"> </p> <p align="justify">o Therapeutic</p> <p align="justify">Perencanaan mengenai tindakan/pengobatan yang akan diberikan.</p> <p align="justify"> </p> <p align="justify">o Patient education</p> <p align="justify">Perencanaan mengenai penyampaian informasi medis kepada pasien.</p> <p align="justify"> </p> <p align="justify">Progress note atau catatan kemajuan berisi data tentang perkembangan kondisi pasien selama proses perawatan. Catatan kemajuan dapat dirumuskan dengan SOAP:</p> <p align="justify">o <b>S</b>ubjective (the patient’s observations)</p> <p align="justify">o <b>O</b>bjective (the Doctor’s observations and tests)</p> <p align="justify">o <b>A</b>ssessment (the Doctor’s understanding of the problem)</p> <p align="justify">o <b>P</b>lans (Goals, action, advice etc.)</p> <p align="justify"> </p> <p align="justify">Kelebihan POMR:</p> <p align="justify">o Pasien ditangani berdasarkan prioritas masalah.</p> <p align="justify">o Data tersusun terklasifikasi berdasarkan masalah.</p> <p align="justify">o Memudahkan evaluasi rekam medis.</p> <p align="justify">o Memudahkan penelitian terhadap masalah tertentu.</p> <p align="justify"> </p> <p align="justify">Kelemahan POMR:</p> <p align="justify">o Perlu penyesuaian yang lama jika baru pertama kali menerapkan sistem tersebut.</p> <p align="justify">o Perlu pelatihan intensif dan komitmen dari seluruh staf untuk melaksanakan POMR secara terpadu.</p> <p align="justify">o Kekurangtelitian merugikan pelayanan.</p> <p align="justify"> </p> <p align="justify">references:</p> <p align="justify">http://en.wikipedia.org/wiki/medical_record</p> <p align="justify"><u>http://www.bmj.com/cgi/reprint/322/7281/275</u></p> <p align="justify">http://www.yoyoke.web.ugm.ac.id</p> <p align="justify">K. Huffman, Edna.1994.<i>Health Information Management</i>.</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-50431682964045727652011-08-28T04:37:00.001-07:002011-08-28T04:37:17.500-07:00Health Information and Medical Records<h3 align="center"><a name="_Toc217710850"></a><a name="_Toc217476268">Draft Pro forma</a></h3> <p align="center">For Development of Your Health Service’s Own Policy</p> <p align="center"><u>(<b>Insert Health Service Name Here</b></u><b>)</b></p> <p align="center"><strong></strong></p> <h4 align="justify"></h4> <h4 align="justify">Health Information and Medical Records</h4> <p align="justify">The ........HS has obligations under the Commonwealth Privacy Act - Privacy Amendment (Private Sector) Act 2000 to maintain the privacy of personal health information. This includes medical records which may be paper and/or electronic files and includes correspondence, faxes and email that contain medical information.</p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> <p align="justify">All staff are responsible for protecting medical records against unauthorised access where those records are stored or transmitted.</p> <p align="justify">All staff are responsible for the creation of and maintaining accurate, legible and reliable records and protecting them against loss.</p> <p align="justify">All staff are responsible for ensuring pathology test results and any other papers containing personal health information are not left where they may be accessed by unauthorised persons.</p> <p align="justify">All staff are responsible for ensuring the safe and secure storage of medical records.</p> <p align="justify">Medical records are the property of ......HS.</p> <p align="justify">Clients have a right to access their medical records. </p> <p align="justify"><b></b></p> <p align="justify"><b>Content</b></p> <ul> <li> <div align="justify">Every client has an individual client health record containing all clinical information relating to him/her. </div> </li> <li> <div align="justify">Every client health record includes a health summary.</div> </li> <li> <div align="justify">Client information such as address, contact person in an emergency, health summary is updated regularly so the record remains current and accurate.</div> </li> <li> <div align="justify">Allergy (known/no known) status is recorded. Alerts are recorded.</div> </li> <li> <div align="justify">Client information is recorded in a way that allows other staff to read, understand and continue client care. </div> </li> <li> <div align="justify">Information is entered into the health record at the time of each consultation (including after hours, home visits, telephone calls) or as soon as possible after.</div> </li> </ul> <p align="justify"><b></b></p> <p align="justify"><b>Access</b></p> <ul> <li> <div align="justify">Access to patient medical records is available to ......HS clinic workers only.</div> </li> <li> <div align="justify">Paper files are not left exposed on the reception desk, in waiting room or other public areas.</div> </li> <li> <div align="justify">Medical information is filed and/or scanned as soon as possible.</div> </li> <li> <div align="justify">Paper records are returned to filing cabinet/compactus/other as soon as possible.</div> </li> <li> <div align="justify">Computers are positioned to prevent unauthorised viewing of patient information. Screen savers are in use. </div> </li> <li> <div align="justify">Electronic records are only accessed by clinical staff via secure login/password.</div> </li> <li> <div align="justify">Electronic records are closed when not in use.</div> </li> <li> <div align="justify">Clinics are locked after hours.</div> </li> </ul> <p align="justify"><a name="_Toc217710851"></a></p> <p align="justify"><a name="_Toc217476270"><b>Procedure – Paper Files</b></a></p> <ul> <li> <div align="justify">Use tracer card when removing a medical record from the filing location. </div> </li> <li> <div align="justify">Return the records to the filing system as soon as possible after use. </div> </li> </ul> <p align="justify"> </p> <p align="justify"><b>Procedure – Electronic/Computer Files</b></p> <ul> <li> <div align="justify">Record closed after use.</div> </li> <li> <div align="justify">Regular backups undertaken.</div> </li> </ul> <h5 align="justify"> </h5> <h5 align="justify">Filing</h5> <ul> <li> <div align="justify">All medical records must be filed for easy retrieval, ongoing use and maintenance. </div> </li> <li> <div align="justify">·All staff are responsible for filing and for the safe storage of medical records.</div> </li> <li> <div align="justify"> .......HS currently uses the numerical/alphabetical/other ...... system for filing paper medical records.</div> </li> <li> <div align="justify">.........HS patients have the following file numbers</div> </li> <li> <div align="justify">Paper file</div> </li> <li> <div align="justify">Electronic record</div> </li> <li> <div align="justify">Hospital registration number (HRN)</div> </li> </ul> <p align="justify"><b></b></p> <p align="justify"><b>Medical Information </b></p> <ul> <li> <div align="justify">Information such as results (pathology, x-ray etc), correspondence or specialist reports are dated and checked prior to being filed within the appropriate medical record as soon as possible. It is important to ensure confidentiality of material waiting to be filed is maintained.</div> </li> <li> <div align="justify">Medical correspondence is scanned/ kept in patient paper file. Once scanned the original copy is shredded.</div> </li> <li> <div align="justify">Electronic results are checked and appropriate action marked.</div> </li> </ul> <p align="justify"><b></b></p> <p align="justify"><b>Errors </b></p> <ul> <li> <div align="justify">Errors in a paper file are corrected by crossing a single line through the entry. This is then initialled, dated with a brief explanation written beside or below. </div> </li> <li> <div align="justify">Errors in an electronic record are noted, recorded and dated by referring to the wrong information.</div> </li> <li> <div align="justify">A client may have their personal information amended if they can prove the information is untrue. </div> </li> </ul> <p align="justify"><b></b></p> <p align="justify"><b>Storage </b></p> <ul> <li> <div align="justify">Clinics are locked after hours.</div> </li> <li> <div align="justify">Backups are performed ........................</div> </li> <li> <div align="justify">Backups are kept in a secure place.</div> </li> <li> <div align="justify">An IT Information Disaster Plan policy is in place. </div> </li> <li> <div align="justify">Paper records are kept in vermin-proof storage when not in use.</div> </li> </ul> <h5 align="justify"> </h5> <h5 align="justify">Transfer of information </h5> <ul> <li> <div align="justify">Transfer of information to and from another provider is only by patient consent. </div> </li> <li> <div align="justify">Information includes name and address of client, date of birth, medicare number, name and address of provider.</div> </li> <li> <div align="justify">Information may only be sent via <b>email</b> if it is securely encrypted. </div> </li> </ul> <p align="justify"><b></b></p> <p align="justify"><b>Faxes </b>must have confidential written on cover sheet. Always check number before being sent.</p> <ul> <li> <div align="justify">Mail requiring to be <b>posted</b> must be left in a secure area out of public view and access. </div> </li> </ul> <p align="justify"><b></b></p> <p align="justify"><b>Removal</b></p> <p align="justify">Paper/electronic records are not removed from the clinics except in the following circumstances:</p> <p align="justify">i. Attending to a patient outside the clinic if a clinic consultation is not possible.</p> <p align="justify">ii. Outstation visits.</p> <p align="justify">iii. Subpoenaed medical records or other valid written warrant requesting the medical record.</p> <p align="justify"><b></b></p> <b> <p align="justify"> <br /></p> </b> <p align="justify"><b>Retention of Records </b></p> <p align="justify">Recommendation 21 of the “<b><i>Bringing them home. Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families</i></b>”, This Recommendation 21 has been adopted by the Federal Government to assist in researching Stolen Generation family links.</p> <p align="justify">“That no records relating to Indigenous individuals, families or communities or to any children, Indigenous or otherwise, removed from their families for any reason, whether held by government or non-government agencies, be destroyed.”</p> <p align="justify"><b></b></p> <p align="justify"><b>Archiving</b></p> <ul> <li> <div align="justify">Where clients have not been seen for between 7 to 15 years, client files can be archived and stored off-site in a secured location. </div> </li> <li> <div align="justify">All clients who are 28 years of age or younger, regardless of the last time they presented for a consultation.</div> </li> <li> <div align="justify">Records are culled annually.</div> </li> <li> <div align="justify">Records of deceased patients are marked, “DECEASED” on the record and filed in a separate/inactive section of the storage area.</div> </li> <li> <div align="justify">Records of Drugs of Addiction stock and administration are retained for a minimum of 3 years.</div> </li> </ul> <p align="justify"><b></b></p> <p align="justify"><b></b></p> <p align="justify"><b>Disposal</b></p> <p align="justify">Medical information that has been scanned into a patient file is shredded in the clinic.</p> <p align="justify"><i></i></p> <p align="justify">RACGP 3<sup>rd</sup> Edition 1.7; 4.2</p> <p align="justify">ISO: Australian Standard for Records Management (AS ISO 15489).</p> <p align="justify">Associated P&P: Confidentiality; Client Access to Personal File; 3<sup>rd</sup> Party Access to Clinical File; Computer Policy </p> <p align="justify"><a title="http://www.medical-record.blogspot.com/" href="http://www.medical-record.blogspot.com/">http://www.medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-54720601894906505042011-08-28T04:31:00.001-07:002011-08-28T04:31:50.809-07:00MEDICAL RECORD CORONARY ABSTRACTING INSTRUKTIONS<p align="center"><b>Medical Record Coronary Abstracting Instructions</b></p> <p align="center"><strong></strong></p> <p align="justify">Indicator: <b><u>Comprehensive Coronary Artery Disease</u></b></p> <p align="justify"><b>               (Clinical Indicator)</b></p> <p align="justify">Reporting for Year: 1999</p> <p align="justify"> </p> <p align="justify"> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td valign="top" width="184"> <p><b>Description: </b></p> </td> <td valign="top" width="526"> <p>The percentage of members between 18 and 75 years of age as of 12/31 of the reporting year who were continuously enrolled during the reporting year, have a diagnosis of coronary artery disease and who are up-to-date for all appropriate services. Also reported is the percentage of components up-to-date.</p> </td> </tr> <tr> <td valign="bottom" width="184"> </td> <td valign="bottom" width="526"> </td> </tr> <tr> <td valign="bottom" width="184"> <p><b>Required sample size:</b></p> </td> <td valign="bottom" width="526"> <p>Sample size of 60 records per medical group</p> </td> </tr> <tr> <td valign="bottom" width="184"> <p><b></b></p> </td> <td valign="bottom" width="526"> </td> </tr> <tr> <td valign="top" width="184"> <p><b>Data elements provided for medical record abstraction tool:</b></p> </td> <td valign="bottom" width="526"> <p>· Member’s medical group</p> <p>· Member’s clinic location as of 12/31 of reporting year</p> <p>· Member’s current clinic location</p> <p>· Member name</p> <p>· Member’s date of birth (DOB)</p> <p>· Member identification number (DEC#, TD#)</p> <p>· Date of last LDL level test</p> <p>· Pharmacy (Rx) benefit</p> <p>· Measurement set</p> <p>· Sort by medical group, clinic, alpha sort by patient name</p> </td> </tr> <tr> <td valign="bottom" width="184"> <p><b></b></p> </td> <td valign="bottom" width="526"> </td> </tr> <tr> <td valign="top" width="184"> <p><b>Record exclusions:</b></p> </td> <td valign="bottom" width="526"> <p>· Member does not have CAD (Column K, 1=yes)</p> <p>· Member was a nursing home resident, hospice resident or died but was not disenrolled during 1999, (Column L, 1=yes)</p> </td> </tr> <tr> <td valign="bottom" width="184"> <p><b></b></p> </td> <td valign="bottom" width="526"> </td> </tr> <tr> <td valign="top" width="184"> <p><b>Data to be collected:</b></p> </td> <td valign="bottom" width="526"> <p>(A) Smoker/advice to quit (A<sub>1</sub>); smoker/no advice to quit (A<sub>2</sub>) (1=yes, 0=no)</p> <p>(B) Nonsmoker (1=yes, 0=no)</p> <p>(C) Unknown tobacco user (1=yes, 0=no)</p> <p>(D) LDL Date (may be prepopulated)</p> <p>(E) LDL level (record actual LDL value)</p> <p>(F) Lipid Rx (1=yes, 0=no, N/A)</p> <p>(G) ASA Use (1=yes, 0=no, N/A=contraindicated)</p> <p>(H) Blood Pressure (H1) systolic; (H2) diastolic</p> <p>(I) Exercise assessment (1=yes, 0=no)</p> <p>(J) Nutrition assessment (1=yes, 0=no)</p> <p>(K) Record indicates the number did not have CAD (1=yes)</p> <p>(L) Nursing home resident, hospice resident or member died in 1999 (1=yes)</p> <p>(M) Record exists; not available for review (1=yes)</p> <p>(N) Record does not exist (1=yes)</p> </td> </tr> <tr> <td valign="bottom" width="184"> <p><b></b></p> </td> <td valign="bottom" width="526"> </td> </tr> <tr> <td valign="top" width="184"> <p><b>Location of data in medical record:</b></p> </td> <td valign="bottom" width="526"> <p>· Medical history/problem list</p> <p>· Preventive summary/risk assessment tools</p> <p>· Provider progress notes</p> <p>· Laboratory data</p> <p>· Smoker/advice to quit/no advice to quit: Most recent visit progress note (up to 12/31/99)</p> <p>· Non-smoker: Label, general form, most recent visit progress note</p> </td> </tr> <tr> <td valign="bottom" width="184"> <p><b></b></p> </td> <td valign="bottom" width="526"> </td> </tr> <tr> <td valign="top" width="184"> <p><b>Data required to generate a positive result:</b></p> </td> <td valign="top" width="526"> <p>A. <b><u>Smoker: advice to quit (A<sub>1</sub>) Most recent visit progress note of ’99.</u> </b>Information at the most recent visit progress note that shows that a user was asked about use at that visit. The visit must be a <i>face-to-face encounter</i> with a health care provider. A provider is defined as an MD, DO, NP, CNM, or PA. Tobacco use includes cigarettes, cigars, pipes or “chew.” If the patient is a child or adolescent (<13), a similar identification should be used to show that the child is not exposed to smoke from a parent, guardian or child care provider (i.e., if the child is breathing the smoke of others regularly, s/he is a smoker). If a special tobacco flowsheet is used, a notation consistent with the date of the last progress notes is adequate. Documentation in the progress note or tobacco flowsheet from the latest visit with a clinician of either advice to quit, or information about the user’s current interest or readiness to quit must exist. “Smoking discussed” is adequate.</p> <p><b><u>Smoker/no advice to quit (A<sub>2</sub>): Most recent visit progress note of ’99.</u></b> Information at the most recent progress note that shows a user was asked about use at that visit. The visit must be a <i>face-to-face encounter</i> with a health care provider. A provider is defined as an MD, DO, NP, CNM, or PA. Tobacco includes cigarettes, cigars, pipes or “chew.” If the patient is a child or adolescent (<13), a similar identification should be used to show that the child is not exposed to smoke from a parent, guardian, or child care provider (i.e., if the child is breathing the smoke of others regularly, s/he is a smoker). If a special tobacco flowsheet is used, a notation consistent with the date of the last progress notes is adequate. If neither advice to quit nor an expression of the user’s interest in quitting is documented, consider no advice given.</p> <p>B. <b><u>Non-Smoker:</u></b> A label or mark anywhere on the chart, or on general forms like a problem list, or on the most recent visit progress note that shows the patient has been asked at least once and reported not using tobacco. If the patient is a child/adolescent (<13), similar documentation should be used to show that the child is not exposed to smoke from a parent, guardian or childcare provider.</p> <p>C. <b><u>Unknown with Medical Record:</u> </b>No label or mark on the chart, or a known user with no documentation at the most recent visit as to the current use status. The visit must be a face-to-face encounter with a health care provider. If a discrepancy exists in the chart (e.g., non-smoking sticker on chart and also a note indicating the patient is a smoker) with no documentation at the most recent visit as to the current use status, status should be considered unknown.<u></u></p> <p>D. <u>LDL drawn in reporting year:</u></p> <p>· LDL must be drawn during a 12-month reporting period ending December 31, 1999.</p> </td> </tr> </tbody></table> </p> <p align="justify"> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td valign="top" width="183"> <p><b>Data required to generate a positive result (cont):</b></p> </td> <td valign="top" width="523"> <p>· Field will be prepopulated with date of last test from claims, etc. files. If no date is entered, check for LDL within reporting year and record date of most recent.</p> <p>· If you find a more recent LDL within 1999 than the date given, you may change the date and enter the level of most recent LDL in Column D.</p> <p>· If no LDL can be found in 1999, Column D = 0.</p> <p>E. <u>LDL Level</u></p> <p>· If multiple LDLs have been drawn over the reporting period, record level of <b>most recent </b>test. </p> <p>· If no LDL level from the reporting period can be found in the medical record, enter “0” in Column E.</p> <p>· If lab result = ULDL indicating triglycerides are too high to calculate a LDL level, enter a LDL level of 300 in Column E.</p> <p>· If no LDL level, the following test values can be recorded on the back of your worksheet to allow us to calculate the LDL level. (We can only calculate the LDL if triglycerides <400): <b>Total cholesterol value, HDL value, Triglycerides value</b>. If <b>lipoprotein </b>is also measured, record this value also. We don’t need this value to calculate the LDL; however, if it is given this value will be used to modify our calculation.</p> <p>F. <u>Lipid Rx</u></p> <p>· Evidence in the medical record that member is using a lipid-lowering drug (drug list attached) at any time during the reporting year.</p> <p>G.<u>ASA Use</u></p> <p>· Evidence in the medical record that member is currently on ASA therapy. Any reference in 1999 for ASA use will be sufficient as long as there is no subsequent evidence in 1999 the member was advised to discontinue ASA.</p> <p>· List of contraindications for ASA use attached.</p> <p>H.<u>Blood Pressure</u></p> <p>· Blood pressure at the most recent visit of the reporting year. Record systolic in (H<sub>1</sub>), and record diastolic in (H<sub>2</sub>).</p> <p>Guidelines for multiple blood pressure readings from a single visit:</p> <p>· <b><i>Multiple BPs in different positions</i></b>–Use sitting BP measurement; if no sitting BP then use supine BP; if no supine then use standing BP.</p> <p>· <b><i>Multiple BPs in a given position</i></b>–Count the lowest BP; the position hierarchy above would still apply.</p> <p>· <b><i>Multiple BPs without an indication of position</i></b>–Use the lowest BP.</p> <p>I. <u>Exercise assessment</u></p> <p>· Exercise assessment documented within reporting year. Example: Risk assessment tool, phone consultation, progress note.</p> <p>J. <u>Nutrition assessment</u></p> <p>· Nutrition assessment documented within reporting year. Example: Risk assessment tool, phone consultation, progress note.</p> <p>K. <u>Documentation in the medical record must indicate the patient has CAD</u> (see attached list for operational definition of coronary artery disease). If no CAD, enter 1 in Column K.<b><u></u></b></p> </td> </tr> </tbody></table> </p> <p align="justify"> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td valign="top" width="183"> <p><b>Data elements required:</b></p> </td> <td valign="top" width="523"> <p>· Member’s medical group</p> <p>· Member’s clinic location as of 12/31 of reporting year</p> <p>· Member’s current clinic location</p> <p>· Member’s name</p> <p>· Member’s date of birth (DOB)</p> <p>· Member identification number</p> <p>· Date of last LDL level test</p> <p>· Pharmacy (Rx) benefit</p> <p>· Measurement set</p> </td> </tr> <tr> <td valign="top" width="184"> <p><b></b></p> </td> <td valign="bottom" width="521"> <p>(O) Smoker/advice to quit (A<sub>1</sub>); smoker/no advice to quit (A<sub>2</sub>) (1=yes, 0=no)</p> <p>(P) Nonsmoker (1=yes, 0=no)</p> <p>(Q) Unknown tobacco user (1=yes, 0=no)</p> <p>(R) LDL Date (may be prepopulated)</p> <p>(S) LDL level (record actual LDL value)</p> <p>(T) Lipid Rx (1=yes, 0=no, N/A)</p> <p>(U) ASA Use (1=yes, 0=no, N/A=contraindicated)</p> <p>(V) Blood Pressure (H1) systolic; (H2) diastolic</p> <p>(W) Exercise assessment (1=yes, 0=no)</p> <p>(X) Nutrition assessment (1=yes, 0=no)</p> <p>(Y) Record indicates the number did not have CAD (1=yes)</p> <p>(Z) Nursing home resident, hospice resident or member died in 1999 (1=yes)</p> <p>(AA) Record exists; not available for review (1=yes)</p> <p>(BB) Record does not exist (1=yes)</p> </td> <td width="1"></td> </tr> <tr> <td width="183"></td> <td width="1"></td> <td width="521"></td> <td width="1"></td> </tr> </tbody></table> </p> <p align="justify"><b>The CPT-4 codes that include LDL are:</b></p> <p align="justify">80061 Lipid panel</p> <p align="justify">83715 Lipoprotein segmentation</p> <p align="justify">83716 High resolution fractionation and quantitation of lipoprotein cholesterols</p> <p align="justify">83717 Lipoprotein centrifuge (deleted CPT code in 1999-will include this year)</p> <p align="justify">83721 LDL </p> <p align="justify"><b>Operational Definition of CAD:</b></p> <p align="justify">The following ICD-9 diagnosis codes are used for identification of CAD:</p> <p align="justify">410.XX AMI</p> <p align="justify">411.XX Post Myocardial Infarction Syndrome</p> <p align="justify">412 Old AMI</p> <p align="justify">413.XX Angina Pectoris (except 413.1 Printzmetal angina)</p> <p align="justify">414.0X Coronary Artherosclerosis</p> <p align="justify">414.10 Aneurysm of Heart Wall</p> <p align="justify">414.8 Other Chronic Ischemic Heart Disease</p> <p align="justify">414.9 Chronic IHD</p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-38422026373996982862011-08-28T04:16:00.001-07:002011-08-28T04:16:08.190-07:00REPORT OF THE COUNCIL ON MEDICAL SERVICE<p align="justify"> </p> <p><a href="http://lh3.ggpht.com/-KSuMJr7Hvcg/TlojWo5ChyI/AAAAAAAABL4/mChrMWaBgk4/s1600-h/medicalrecords2.jpg"><img title="medical records" style="border-top-width: 0px; display: inline; border-left-width: 0px; border-bottom-width: 0px; margin-left: 0px; margin-right: 0px; border-right-width: 0px" height="110" alt="medical records" src="http://lh6.ggpht.com/-9pSVuOEZrWI/TlojaLa79GI/AAAAAAAABL8/JrT_tJ_b0aQ/medicalrecords_thumb.jpg?imgmax=800" width="98" align="left" border="0" /></a> CMS Report 10 - A-00</p> <p>(June 2000)</p> <p> </p> <p> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td valign="top" width="96"> <p>Subject:</p> </td> <td valign="top" width="347"> <p>Electronic Medical Records Systems</p> </td> </tr> <tr> <td valign="top" width="96"> <p>Presented by:</p> </td> <td valign="top" width="347"> <p>Eugene Ogrod, MD, Chair</p> </td> </tr> </tbody></table> </p> <p align="justify"><a title="http://medical-record.blogspot.com/" href="http://medical-record.blogspot.com/">http://medical-record.blogspot.com/</a></p> <p align="justify"> </p> <p align="justify">At the 1998 Annual Meeting, the House of Delegates adopted the following recommendation in Council on Medical Service Report 1:</p> <p align="justify">That the AMA define the critical elements that an electronic medical record (EMR) system should have the capacity to record, although some of these elements may not be used by all parties and/or may require refinement for effective use.</p> <p align="justify">The following report, which is presented for the information of the House, summarizes electronic medical record trends; addresses issues such as health data element standards and data sets; outlines and discusses some of the characteristics and features of key inter-related core components of ambulatory EMRs; reviews the results of the AMA’s core clinical data elements survey; discusses some of the barriers or obstacles to implementation of EMRs; and presents current information related to security and interoperability. </p> <h6 align="justify"></h6> <h4 align="justify"> </h4> <h4 align="justify">ELECTRONIC MEDICAL RECORD TRENDS</h4> <p align="justify">When describing an electronic medical or patient records system, different associations, vendors, and institutions use varying terminology and definitions. Some organizations make a clear delineation between the definitions, whereas others use terminology interchangeably.</p> <p align="justify">According to the Medical Records Institute (MRI), the EMR is an upgraded version of the computerized medical record that has essentially the same structure, scope, and information as the paper-based record. However, the information is rearranged for computer use. In addition, the MRI believes such a system should be capable of appropriately capturing, processing, and storing information and be interoperable with other related systems such as billing and administration.</p> <p align="justify">Furthermore, the MRI believes that the electronic medical record is a concept that has a number of criteria, such as being paperless, complying with documentation rules (e.g., data integrity, authenticity, availability, and auditability, etc.) as well as being platform and institution-independent. Systems may comply with some or all of these concept requirements.</p> <p align="justify">A survey of electronic health record trends and usage was recently conducted by the MRI that reveals a number of the following insights into the motivations driving the need for EMRs, the major barriers, and associated security concerns: </p> <p align="justify">Major management/administrative factors driving the need for EMRs include the need to share comparable patient data among different sites within a multi-entity health care delivery system as well as the need to establish a more efficient and effective information infrastructure as a competitive advantage.</p> <p align="justify">Major clinical factors driving the need for EMRs include improving the ability to share patient record information among providers as well as improving the quality of care.</p> <p align="justify">Major barriers to implementation include lack of adequate funding or resources and inadequate or incomplete health care information standards, data sets, or code sets.</p> <p align="justify">Major concerns regarding the security of patient record information include access to patient record information by unauthorized users as well as inappropriate access to patient record information by authorized users inside the organization.</p> <p align="justify">Complete results of the survey are available at www.medrecinst.com.</p> <h5 align="justify">DATA ELEMENT STANDARDS AND DATA SETS</h5> <p align="justify">There are few established health data element standards for electronic medical records are few. Two known core data sets, each published in 1996, are the National Committee for Vital and Health Statistics (NCVHS) Core Health Data Elements and the American Society for Testing and </p> <p align="justify">Materials (ASTM) Minimum Essential Data Set. The core health data set proposed by NCVHS for standardization consists of 42 elements. Twenty-six of the 42 elements are identified </p> <p align="justify">as being “ready for implementation,” whereas “substantial agreement has been reached, but some additional work is needed” on 10 of the elements. The remaining six are “recognized as significant, but considerable work remains to be undertaken.” The data set, included as part of a complete report on core health data elements, can be downloaded directly from the NCVHS Web site at: http:// www.ncvhs.hhs.gov/ncvhsr1.htm. </p> <p align="justify">The ASTM data set is part of the ASTM American National Standard <u>E 1384-96: Standard Guide for Content and Structure of the Computer-Based Patient Record</u> (recently revised to <u>E 1384-99 Standard Guide for Content and Structure of the Electronic Health Record</u>) and consists of 116 data elements divided into the following entities:</p> <p align="justify">Patient</p> <p align="justify">Encounter</p> <p align="justify">Problem</p> <p align="justify">Order-Care/Treatment Plan</p> <p align="justify">Provider</p> <p align="justify">Observation-History</p> <p align="justify">Observation-Assessment/Exams</p> <p align="justify">Observations-Diagnostic Tests</p> <p align="justify">Observation-Encounter/Episode Detail </p> <p align="justify">Service Instance</p> <p align="justify">Information regarding ASTM standards can be found on its Web site: http://www.astm.org. The number of computer software vendors that have incorporated either the ASTM standard or NCVHS data set remains unknown. In addition, the overall lack of a solution for standards for data recording and transmission, and the assurance of security, privacy, and confidentiality in record storage and transmission, have prohibited professional organizations from endorsing or truly supporting either of these data sets.</p> <h5 align="justify"> </h5> <h5 align="justify">KEY COMPONENTS OF ELECTRONIC MEDICAL RECORD SYSTEMS</h5> <p align="justify"><u></u></p> <p align="justify">Although the availability of the full range of core clinical data elements is perhaps the area of most concern to practicing physicians as they evaluate potential EMR systems, ambulatory electronic medical record systems are comprised of a set of several inter-related key components. These components together form the technical and clinical requirements of an optimal paperless patient record and the evaluation of an EMR system for an ambulatory setting demands attention to each component. Review of the literature identified a total of seven key component categories of ambulatory electronic medical record systems as necessary for evaluation:</p> <p align="justify"><u></u></p> <p align="justify">Data entry:</p> <p align="justify">Provides flexible data entry options</p> <p align="justify">Supports a choice of data entry devices</p> <p align="justify">Provides modifiable templates to facilitate direct data entry at the point of care</p> <p align="justify">Provides pick lists for common responses</p> <p align="justify">Provides data merging from templates to progress notes</p> <p align="justify">Provides drawing tools for genograms</p> <p align="justify">Provides drawing tools with templates to document the presence of lesions, injuries, etc.</p> <p align="justify">Supports a wide range of coding options</p> <p align="justify">Provides mechanism for entry and validation of electronic signatures</p> <p align="justify">Allows direct data entry by physicians, nurses and other providers</p> <p align="justify">Allows entry of transcribed provider notes</p> <p align="justify">Allows multiple providers to view and write to the same chart simultaneously</p> <p align="justify">Data display:</p> <p align="justify">Provides practical data presentation formats</p> <p align="justify">Allows automatic text generation</p> <p align="justify">Provides custom views of results</p> <p align="justify"><u></u></p> <p align="justify">Communications/connectivity:</p> <p align="justify">Standards compliant</p> <p align="justify">Bi-directional interfaces</p> <p align="justify">Ability to transmit documents via facsimile</p> <p align="justify">Ability to transmit documents via email</p> <p align="justify">Internet capabilities</p> <p align="justify">Integrated Web browser</p> <p align="justify">Technical features:</p> <p align="justify">Database type</p> <p align="justify">Structured data content/data elements</p> <p align="justify">Data warehouse capabilities</p> <p align="justify">Data access-decision support software</p> <p align="justify">Network</p> <p align="justify">Operating system</p> <p align="justify">Performance</p> <p align="justify">System security and privacy of data/data integrity</p> <p align="justify"><u></u></p> <p align="justify">Workflow and record management:</p> <p align="justify">Facilitates patient record management</p> <p align="justify">Supports patient scheduling</p> <p align="justify">Records patient information and demographics</p> <p align="justify"><u></u></p> <p align="justify">Clinical documentation and decision support functions</p> <p align="justify">Summary screen</p> <p align="justify">Problem lists</p> <p align="justify">Clinical decision support tools</p> <p align="justify">Medications/prescriptions support</p> <p align="justify">Imaging</p> <p align="justify">Labs</p> <p align="justify">Reminders and alerts</p> <p align="justify">Consultations</p> <p align="justify">Health care maintenance-preventive care</p> <p align="justify">Order entry capabilities</p> <p align="justify">Letters and forms</p> <p align="justify">Health status and functional level measurement</p> <p align="justify">Patient educational resources</p> <p align="justify">Quality management and reporting capability</p> <p align="justify">Managed care/insurance support</p> <p align="justify">Core clinical data elements:</p> <p align="justify">Patient Identification and Demographic Data</p> <p align="justify">Special Patient Health Conditions</p> <p align="justify">Allergies</p> <p align="justify">Immunizations</p> <p align="justify">Health Promotion/Disease Prevention</p> <p align="justify">Past Medical History</p> <p align="justify">Family and Social History</p> <p align="justify">Encounter/Visit Administrative Information</p> <p align="justify">Encounter/Visit Clinical Information</p> <p align="justify">Laboratory Tests Orders and Results</p> <p align="justify">Other Diagnostic Procedures Orders and Results</p> <p align="justify">Therapeutic Services and Procedures Orders and Results</p> <p align="justify">Medications Prescribed and Results</p> <p align="justify">Consultations and Referrals</p> <p align="justify">Correspondence/Release of Information</p> <h5 align="justify"> </h5> <h5 align="justify">AMA CORE CLINICAL DATA ELEMENTS SURVEY</h5> <p align="justify">The Council believes that of the key EMR components described in the previous section, the category of most concern to practicing physicians is core clinical data elements. In addition, this is the area where practice management software vendors continue to fall short in development of their products. Therefore, on behalf of the AMA, Medical Systems Development, a firm specializing in market analyses of electronic medical records and practice management systems, developed a report identifying a comprehensive list of core clinical data elements that an electronic medical record system should have the capacity to record. These data elements were derived from a large number of diverse resources including uniform data sets, accrediting and licensing agency requirements, industry standards, selected EMR literature, and EMR vendor system specifications.</p> <p align="justify">The AMA then developed a survey tool based on the market analysis to gather the opinions of 29 external advisors with expertise in paper-based medical record systems, computer applications in clinical care, and experience developing electronic medical record systems in academia and the government. The list of core clinical data elements included in the survey was not intended to represent a minimum data set. In addition, the survey tool indicated that the data for each listed data element did not have to be recorded for every patient. However, the 500-plus elements included on the survey were intended to represent a comprehensive listing of data elements that should be available in an optimal EMR system. Therefore, the advisors were asked to review the data elements and assess the appropriateness of each data element for inclusion in a final list of recommended core clinical data elements for an ambulatory EMR system.</p> <p align="justify">General feedback from the survey revealed that all the presently listed core clinical data elements, along with a few suggestions from the advisors, should be further analyzed by a standards group to determine their functionality (required or conditional). The survey tool, including comments to the overall survey, is available on the AMA Web site at http://www.ama-assn.org. The Council believes that the results of this survey could provide standards development organizations, as well as electronic medical record system software vendors, with a coveted and viable source of information they can use in the development of future standards and products. Since specific standards work does not exist in this area, two standards development organizations, ASTM and Health Level Seven (HL7), have already expressed interest in the outcome of this survey</p> <p align="justify"><b></b></p> <p align="justify"><u></u></p> <p align="justify"><u>BARRIERS TO EMR IMPLEMENTATION </u></p> <p align="justify">One of the biggest barriers in health care information technology remains the lack of standards. A standard is a clearly defined and agreed-upon convention for the operation and behavior of specific computing functions, formats, and processes. Standards are deficient for an EMR in a number of areas, including but not limited to medical vocabulary, common identifiers, data exchange, and privacy and confidentiality. In addition, standards are lacking in the categories of system interfaces and interoperability. This latter deficiency is especially troublesome because the underlying technology and infrastructure of an EMR must incorporate the ability to communicate between one system and another. </p> <p align="justify">Many organizations are addressing standards and issues related to the EMR. However, no organization is focusing on the necessity for vendors to incorporate the specific needs of the practicing physician in the ambulatory care setting. Since there is no agreed upon standardized EMR system for ambulatory care, the vendor community is creating a variety of EMR systems that are often incompatible. This situation leaves little guidance for physicians in selecting an EMR. </p> <p align="justify">As stated previously, the Council believes that the results of the AMA core clinical data elements survey could provide standards development organizations, as well as electronic medical record system software vendors, with a coveted and viable source of information they can use in the development of future standards and products. Since specific standards work does not exist in this area, and both ASTM and HL7 have expressed interest in the survey outcome, the results will be shared with the standards developing organizations.</p> <p align="justify"><u></u></p> <p align="justify"><u>SECURITY AND INTEROPERABILITY</u></p> <p align="justify">In CMS Report 7 (I-98), the Council recommended that the AMA work to establish consensus on industry security guidelines for electronic storage and transmission of medical records as an important means of protecting patient privacy. The AMA is currently working with Intelâ Corporation on a system to provide digital certificates to physicians for use on the Internet. It will protect physician and patient privacy and confidentiality when they use the Internet to send and receive medical information. The AMA will begin issuing digital certificates to physicians by the third quarter of 2000. The digital certificates will uniquely identify individuals over the Internet, providing a more reliable authentication technique than do passwords for secure Internet transactions. Digital certificates function in the online world in the same way driver licenses, passports, and other trusted documents function in the paper world.</p> <p align="justify">The AMA and Intel believe that the potential for physicians to use the Internet as a tool to obtain data such as lab results, or to send prescriptions to pharmacies, in addition to storing and retrieving patient files, makes it vitally important that systems are in place to ensure that the patient’s privacy and confidentiality are protected. Furthermore, by authenticating the identity of the physician, this system will allow for a wide and growing variety of routine medical transactions to occur online. Ultimately, this development will enable better patient care and lessen the administrative burden on busy physicians and their staffs. </p> <p align="justify">Additional information regarding the AMA and Intel Digital Credential Management System to identify physicians on the Internet can be found in Board of Trustees’ Report, “Health Data and Modern Medical Professionalism” (A-00). </p> <p align="justify"><u></u></p> <p align="justify"><u></u></p> <p align="justify"><u>CONCLUSION</u></p> <p align="justify">It is clear that physicians and their patients can derive important benefits from broader use of EMR systems that adequately address the dimensions that are identified in this report. At the same time, the Council recognizes that there are important issues related to potential impact on physician time, cost, patient care, and confidentiality. In addition, the Council realizes that current EMR systems are not fully supporting physician needs.</p> <p align="justify">Based on the current marketplace and obstacles, the Council believes that it is premature for the AMA to suggest a specific standardized EMR system for use in the ambulatory setting. The Council also believes that, based on substantial input from practicing physicians, accelerated progress in the EMR area is imperative. This progress should address the need for greater standardization and the specific EMR dimensions identified previously in this report. </p> <p align="justify">Furthermore, the Council believes that the component of the EMR that is of most concern to practicing physicians is in the area of core clinical data elements. Moreover, this is the area where practice management software vendors continue to fall short in development of their products. However, as stated previously, standards work presently does not exist in this area. Therefore, the Council believes that results of the survey tool including the comprehensive list of core clinical data elements should be shared with the appropriate standards development organization(s), since the true functionality of each element could be better determined within the standards community. AMA participation in this project is crucial in order to make the computer a useful tool for creating a more efficient work environment for the physician. Without the AMA efforts, standards will be modified to medicine rather than developed specifically for the profession. </p> <p align="justify"><a title="http://medical-record.blogspot.com/" href="http://medical-record.blogspot.com/">http://medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-66168862273579814962011-08-28T04:10:00.001-07:002011-08-28T04:10:22.182-07:00REPORT OF THE COUNCIL ON MEDICAL SERVICE<p align="justify"> </p> <p><a href="http://lh4.ggpht.com/-Nl1weIjK0dc/Tloh8r1LGZI/AAAAAAAABLw/j3c3MZlpTV0/s1600-h/medical%252520records%25255B2%25255D.jpg"><img title="medical records" style="border-right: 0px; border-top: 0px; display: inline; margin-left: 0px; border-left: 0px; margin-right: 0px; border-bottom: 0px" height="110" alt="medical records" src="http://lh6.ggpht.com/-AL7jxqYndq4/TloiC-4sdxI/AAAAAAAABL0/m2SCfrdF9xE/medical%252520records_thumb.jpg?imgmax=800" width="98" align="left" border="0" /></a> CMS Report 10 - A-00</p> <p>(June 2000)</p> <p> </p> <p> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td valign="top" width="96"> <p>Subject:</p> </td> <td valign="top" width="347"> <p>Electronic Medical Records Systems</p> </td> </tr> <tr> <td valign="top" width="96"> <p>Presented by:</p> </td> <td valign="top" width="347"> <p>Eugene Ogrod, MD, Chair</p> </td> </tr> </tbody></table> </p> <p align="justify"><a title="http://medical-record.blogspot.com/" href="http://medical-record.blogspot.com/">http://medical-record.blogspot.com/</a></p> <p align="justify"> </p> <p align="justify">At the 1998 Annual Meeting, the House of Delegates adopted the following recommendation in Council on Medical Service Report 1:</p> <p align="justify">That the AMA define the critical elements that an electronic medical record (EMR) system should have the capacity to record, although some of these elements may not be used by all parties and/or may require refinement for effective use.</p> <p align="justify">The following report, which is presented for the information of the House, summarizes electronic medical record trends; addresses issues such as health data element standards and data sets; outlines and discusses some of the characteristics and features of key inter-related core components of ambulatory EMRs; reviews the results of the AMA’s core clinical data elements survey; discusses some of the barriers or obstacles to implementation of EMRs; and presents current information related to security and interoperability. </p> <h6 align="justify"></h6> <h4 align="justify"> </h4> <h4 align="justify">ELECTRONIC MEDICAL RECORD TRENDS</h4> <p align="justify">When describing an electronic medical or patient records system, different associations, vendors, and institutions use varying terminology and definitions. Some organizations make a clear delineation between the definitions, whereas others use terminology interchangeably.</p> <p align="justify">According to the Medical Records Institute (MRI), the EMR is an upgraded version of the computerized medical record that has essentially the same structure, scope, and information as the paper-based record. However, the information is rearranged for computer use. In addition, the MRI believes such a system should be capable of appropriately capturing, processing, and storing information and be interoperable with other related systems such as billing and administration.</p> <p align="justify">Furthermore, the MRI believes that the electronic medical record is a concept that has a number of criteria, such as being paperless, complying with documentation rules (e.g., data integrity, authenticity, availability, and auditability, etc.) as well as being platform and institution-independent. Systems may comply with some or all of these concept requirements.</p> <p align="justify">A survey of electronic health record trends and usage was recently conducted by the MRI that reveals a number of the following insights into the motivations driving the need for EMRs, the major barriers, and associated security concerns: </p> <p align="justify">Major management/administrative factors driving the need for EMRs include the need to share comparable patient data among different sites within a multi-entity health care delivery system as well as the need to establish a more efficient and effective information infrastructure as a competitive advantage.</p> <p align="justify">Major clinical factors driving the need for EMRs include improving the ability to share patient record information among providers as well as improving the quality of care.</p> <p align="justify">Major barriers to implementation include lack of adequate funding or resources and inadequate or incomplete health care information standards, data sets, or code sets.</p> <p align="justify">Major concerns regarding the security of patient record information include access to patient record information by unauthorized users as well as inappropriate access to patient record information by authorized users inside the organization.</p> <p align="justify">Complete results of the survey are available at www.medrecinst.com.</p> <h5 align="justify">DATA ELEMENT STANDARDS AND DATA SETS</h5> <p align="justify">There are few established health data element standards for electronic medical records are few. Two known core data sets, each published in 1996, are the National Committee for Vital and Health Statistics (NCVHS) Core Health Data Elements and the American Society for Testing and </p> <p align="justify">Materials (ASTM) Minimum Essential Data Set. The core health data set proposed by NCVHS for standardization consists of 42 elements. Twenty-six of the 42 elements are identified </p> <p align="justify">as being “ready for implementation,” whereas “substantial agreement has been reached, but some additional work is needed” on 10 of the elements. The remaining six are “recognized as significant, but considerable work remains to be undertaken.” The data set, included as part of a complete report on core health data elements, can be downloaded directly from the NCVHS Web site at: http:// www.ncvhs.hhs.gov/ncvhsr1.htm. </p> <p align="justify">The ASTM data set is part of the ASTM American National Standard <u>E 1384-96: Standard Guide for Content and Structure of the Computer-Based Patient Record</u> (recently revised to <u>E 1384-99 Standard Guide for Content and Structure of the Electronic Health Record</u>) and consists of 116 data elements divided into the following entities:</p> <p align="justify">Patient</p> <p align="justify">Encounter</p> <p align="justify">Problem</p> <p align="justify">Order-Care/Treatment Plan</p> <p align="justify">Provider</p> <p align="justify">Observation-History</p> <p align="justify">Observation-Assessment/Exams</p> <p align="justify">Observations-Diagnostic Tests</p> <p align="justify">Observation-Encounter/Episode Detail </p> <p align="justify">Service Instance</p> <p align="justify">Information regarding ASTM standards can be found on its Web site: http://www.astm.org. The number of computer software vendors that have incorporated either the ASTM standard or NCVHS data set remains unknown. In addition, the overall lack of a solution for standards for data recording and transmission, and the assurance of security, privacy, and confidentiality in record storage and transmission, have prohibited professional organizations from endorsing or truly supporting either of these data sets.</p> <h5 align="justify"> </h5> <h5 align="justify">KEY COMPONENTS OF ELECTRONIC MEDICAL RECORD SYSTEMS</h5> <p align="justify"><u></u></p> <p align="justify">Although the availability of the full range of core clinical data elements is perhaps the area of most concern to practicing physicians as they evaluate potential EMR systems, ambulatory electronic medical record systems are comprised of a set of several inter-related key components. These components together form the technical and clinical requirements of an optimal paperless patient record and the evaluation of an EMR system for an ambulatory setting demands attention to each component. Review of the literature identified a total of seven key component categories of ambulatory electronic medical record systems as necessary for evaluation:</p> <p align="justify"><u></u></p> <p align="justify">Data entry:</p> <p align="justify">Provides flexible data entry options</p> <p align="justify">Supports a choice of data entry devices</p> <p align="justify">Provides modifiable templates to facilitate direct data entry at the point of care</p> <p align="justify">Provides pick lists for common responses</p> <p align="justify">Provides data merging from templates to progress notes</p> <p align="justify">Provides drawing tools for genograms</p> <p align="justify">Provides drawing tools with templates to document the presence of lesions, injuries, etc.</p> <p align="justify">Supports a wide range of coding options</p> <p align="justify">Provides mechanism for entry and validation of electronic signatures</p> <p align="justify">Allows direct data entry by physicians, nurses and other providers</p> <p align="justify">Allows entry of transcribed provider notes</p> <p align="justify">Allows multiple providers to view and write to the same chart simultaneously</p> <p align="justify">Data display:</p> <p align="justify">Provides practical data presentation formats</p> <p align="justify">Allows automatic text generation</p> <p align="justify">Provides custom views of results</p> <p align="justify"><u></u></p> <p align="justify">Communications/connectivity:</p> <p align="justify">Standards compliant</p> <p align="justify">Bi-directional interfaces</p> <p align="justify">Ability to transmit documents via facsimile</p> <p align="justify">Ability to transmit documents via email</p> <p align="justify">Internet capabilities</p> <p align="justify">Integrated Web browser</p> <p align="justify">Technical features:</p> <p align="justify">Database type</p> <p align="justify">Structured data content/data elements</p> <p align="justify">Data warehouse capabilities</p> <p align="justify">Data access-decision support software</p> <p align="justify">Network</p> <p align="justify">Operating system</p> <p align="justify">Performance</p> <p align="justify">System security and privacy of data/data integrity</p> <p align="justify"><u></u></p> <p align="justify">Workflow and record management:</p> <p align="justify">Facilitates patient record management</p> <p align="justify">Supports patient scheduling</p> <p align="justify">Records patient information and demographics</p> <p align="justify"><u></u></p> <p align="justify">Clinical documentation and decision support functions</p> <p align="justify">Summary screen</p> <p align="justify">Problem lists</p> <p align="justify">Clinical decision support tools</p> <p align="justify">Medications/prescriptions support</p> <p align="justify">Imaging</p> <p align="justify">Labs</p> <p align="justify">Reminders and alerts</p> <p align="justify">Consultations</p> <p align="justify">Health care maintenance-preventive care</p> <p align="justify">Order entry capabilities</p> <p align="justify">Letters and forms</p> <p align="justify">Health status and functional level measurement</p> <p align="justify">Patient educational resources</p> <p align="justify">Quality management and reporting capability</p> <p align="justify">Managed care/insurance support</p> <p align="justify">Core clinical data elements:</p> <p align="justify">Patient Identification and Demographic Data</p> <p align="justify">Special Patient Health Conditions</p> <p align="justify">Allergies</p> <p align="justify">Immunizations</p> <p align="justify">Health Promotion/Disease Prevention</p> <p align="justify">Past Medical History</p> <p align="justify">Family and Social History</p> <p align="justify">Encounter/Visit Administrative Information</p> <p align="justify">Encounter/Visit Clinical Information</p> <p align="justify">Laboratory Tests Orders and Results</p> <p align="justify">Other Diagnostic Procedures Orders and Results</p> <p align="justify">Therapeutic Services and Procedures Orders and Results</p> <p align="justify">Medications Prescribed and Results</p> <p align="justify">Consultations and Referrals</p> <p align="justify">Correspondence/Release of Information</p> <h5 align="justify"> </h5> <h5 align="justify">AMA CORE CLINICAL DATA ELEMENTS SURVEY</h5> <p align="justify">The Council believes that of the key EMR components described in the previous section, the category of most concern to practicing physicians is core clinical data elements. In addition, this is the area where practice management software vendors continue to fall short in development of their products. Therefore, on behalf of the AMA, Medical Systems Development, a firm specializing in market analyses of electronic medical records and practice management systems, developed a report identifying a comprehensive list of core clinical data elements that an electronic medical record system should have the capacity to record. These data elements were derived from a large number of diverse resources including uniform data sets, accrediting and licensing agency requirements, industry standards, selected EMR literature, and EMR vendor system specifications.</p> <p align="justify">The AMA then developed a survey tool based on the market analysis to gather the opinions of 29 external advisors with expertise in paper-based medical record systems, computer applications in clinical care, and experience developing electronic medical record systems in academia and the government. The list of core clinical data elements included in the survey was not intended to represent a minimum data set. In addition, the survey tool indicated that the data for each listed data element did not have to be recorded for every patient. However, the 500-plus elements included on the survey were intended to represent a comprehensive listing of data elements that should be available in an optimal EMR system. Therefore, the advisors were asked to review the data elements and assess the appropriateness of each data element for inclusion in a final list of recommended core clinical data elements for an ambulatory EMR system.</p> <p align="justify">General feedback from the survey revealed that all the presently listed core clinical data elements, along with a few suggestions from the advisors, should be further analyzed by a standards group to determine their functionality (required or conditional). The survey tool, including comments to the overall survey, is available on the AMA Web site at http://www.ama-assn.org. The Council believes that the results of this survey could provide standards development organizations, as well as electronic medical record system software vendors, with a coveted and viable source of information they can use in the development of future standards and products. Since specific standards work does not exist in this area, two standards development organizations, ASTM and Health Level Seven (HL7), have already expressed interest in the outcome of this survey</p> <p align="justify"><b></b></p> <p align="justify"><u></u></p> <p align="justify"><u>BARRIERS TO EMR IMPLEMENTATION </u></p> <p align="justify">One of the biggest barriers in health care information technology remains the lack of standards. A standard is a clearly defined and agreed-upon convention for the operation and behavior of specific computing functions, formats, and processes. Standards are deficient for an EMR in a number of areas, including but not limited to medical vocabulary, common identifiers, data exchange, and privacy and confidentiality. In addition, standards are lacking in the categories of system interfaces and interoperability. This latter deficiency is especially troublesome because the underlying technology and infrastructure of an EMR must incorporate the ability to communicate between one system and another. </p> <p align="justify">Many organizations are addressing standards and issues related to the EMR. However, no organization is focusing on the necessity for vendors to incorporate the specific needs of the practicing physician in the ambulatory care setting. Since there is no agreed upon standardized EMR system for ambulatory care, the vendor community is creating a variety of EMR systems that are often incompatible. This situation leaves little guidance for physicians in selecting an EMR. </p> <p align="justify">As stated previously, the Council believes that the results of the AMA core clinical data elements survey could provide standards development organizations, as well as electronic medical record system software vendors, with a coveted and viable source of information they can use in the development of future standards and products. Since specific standards work does not exist in this area, and both ASTM and HL7 have expressed interest in the survey outcome, the results will be shared with the standards developing organizations.</p> <p align="justify"><u></u></p> <p align="justify"><u>SECURITY AND INTEROPERABILITY</u></p> <p align="justify">In CMS Report 7 (I-98), the Council recommended that the AMA work to establish consensus on industry security guidelines for electronic storage and transmission of medical records as an important means of protecting patient privacy. The AMA is currently working with Intelâ Corporation on a system to provide digital certificates to physicians for use on the Internet. It will protect physician and patient privacy and confidentiality when they use the Internet to send and receive medical information. The AMA will begin issuing digital certificates to physicians by the third quarter of 2000. The digital certificates will uniquely identify individuals over the Internet, providing a more reliable authentication technique than do passwords for secure Internet transactions. Digital certificates function in the online world in the same way driver licenses, passports, and other trusted documents function in the paper world.</p> <p align="justify">The AMA and Intel believe that the potential for physicians to use the Internet as a tool to obtain data such as lab results, or to send prescriptions to pharmacies, in addition to storing and retrieving patient files, makes it vitally important that systems are in place to ensure that the patient’s privacy and confidentiality are protected. Furthermore, by authenticating the identity of the physician, this system will allow for a wide and growing variety of routine medical transactions to occur online. Ultimately, this development will enable better patient care and lessen the administrative burden on busy physicians and their staffs. </p> <p align="justify">Additional information regarding the AMA and Intel Digital Credential Management System to identify physicians on the Internet can be found in Board of Trustees’ Report, “Health Data and Modern Medical Professionalism” (A-00). </p> <p align="justify"><u></u></p> <p align="justify"><u></u></p> <p align="justify"><u>CONCLUSION</u></p> <p align="justify">It is clear that physicians and their patients can derive important benefits from broader use of EMR systems that adequately address the dimensions that are identified in this report. At the same time, the Council recognizes that there are important issues related to potential impact on physician time, cost, patient care, and confidentiality. In addition, the Council realizes that current EMR systems are not fully supporting physician needs.</p> <p align="justify">Based on the current marketplace and obstacles, the Council believes that it is premature for the AMA to suggest a specific standardized EMR system for use in the ambulatory setting. The Council also believes that, based on substantial input from practicing physicians, accelerated progress in the EMR area is imperative. This progress should address the need for greater standardization and the specific EMR dimensions identified previously in this report. </p> <p align="justify">Furthermore, the Council believes that the component of the EMR that is of most concern to practicing physicians is in the area of core clinical data elements. Moreover, this is the area where practice management software vendors continue to fall short in development of their products. However, as stated previously, standards work presently does not exist in this area. Therefore, the Council believes that results of the survey tool including the comprehensive list of core clinical data elements should be shared with the appropriate standards development organization(s), since the true functionality of each element could be better determined within the standards community. AMA participation in this project is crucial in order to make the computer a useful tool for creating a more efficient work environment for the physician. Without the AMA efforts, standards will be modified to medicine rather than developed specifically for the profession. </p> <p align="justify"><a title="http://medical-record.blogspot.com/" href="http://medical-record.blogspot.com/">http://medical-record.blogspot.com/</a></p> Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-30807621008316777892011-05-26T09:19:00.000-07:002011-05-26T09:19:16.499-07:00IRB Guidance<div style="text-align: justify;">University of Pittsburgh IRB Guidance on Research Limited to Retrospective Medical Record Reviews<br />
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<a href="http://medical-record.blogspot.com/">http://medical-record.blogspot.com/</a><br />
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Research studies involving the retrospective review, collection and analysis of medical record information are descriptive studies that ordinarily seek to evaluate relationships between one or more biomedical, treatment, and/or demographic variables and one or more outcome measures in patients. Data may include a wide range of information from the medical record (e.g., results of lab tests, nursing and physician notes, summary reports – including intake and discharge summaries and consultant reports, raw data from electrophysiological or imaging tests, etc.). Because this is research, University IRB oversight is required, in accordance with the Federal Policy regulations (45 CFR Part 46) governing human subject protections. Further, because the research involves medical records, compliance with the HIPAA Privacy Rule (46 CFR Part 160; Part 164 (subparts A,E) ) is required. Regarding the latter, the University IRB also serves as the HIPAA privacy board for UPMC.<br />
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There are several different approaches to the conduct of retrospective medical record research studies that can be approved by the University IRB. <br />
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A. Recording of Medical Information, Without Identifiers, By or Under the Oversight Of a Principal Investigator Who Would Normally Have Access to this Information by Virtue of His/Her Patient Care Responsibilities: <br />
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An investigator may personally review medical records and abstract relevant data from the medical records if ALL of the following conditions are met:<br />
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1. All medical records to be accessed for study are currently in existence at the time of the IRB submission. <br />
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2. The desired medical record data is recorded by the investigator in such a way that the respective patients cannot be identified (i.e., by the investigator or others) either directly, or indirectly via linkage codes assigned to the data. This means that the investigator cannot record names, social security numbers, or any other patient identifiers and link this information to the data set. As a consequence, the resulting research data set is necessarily completely anonymous. For that reason, once the information has been extracted from the medical record, it will not be possible for the investigator to go back to the medical record and add other patient-specific information to this research dataset. <br />
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3. The principal investigator (P.I.) of the research study has legitimate access to the desired medical information insofar as he or she is a UPMC staff member and/or has been granted UPMC privileges and provides related care (i.e., related to the information desired) to the patients, or is in the position to provide related care (including treatment, and/or diagnostic services) to the patients. For example, any health professional providing patient care to a particular set of patients (e.g., all patients treated in the Emergency Department; all patients with aphasia; all patients undergoing CT scans), would ordinarily have access to the related medical record information of those patients as part of his or her current or future job responsibilities, and hence would be in a position to serve as the P.I. of a research study involving a retrospective review of those medical records (regardless of whether he or she actually provided direct care to those particular patients). For example, if the research study is directed at obtaining neurological information and the P.I. is a cardiologist, the research submission to the IRB must address the relationship of the information desired to the normal patient care responsibilities of this cardiologist-P.I. Note that the University IRB will not approve a retrospective medical record research study if the medical record information desired is not in some way related to the patient care responsibilities of the listed P.I. That type of study would require the use of a UPMC certified honest broker (see section B). <br />
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It is recognized that health care professional students (including medical students, residents and fellows) may be required to perform a research project and that many of these projects will involve retrospective medical record reviews. It is further recognized that these students may have had limited or transient involvement in the care of these patients. Thus, if the researcher is a health care professional student, the P.I. for the retrospective medical record research study must be a UPMC staff member or UPMC-privileged professional who provides related care, or is in the position to provide related care, to the particular patient population to be studied by the student. In this example, the P.I. on the IRB submission will be the faculty member, and the student will be listed as a co-investigator (or as a Co-Principal Investigator). Please note that in this situation the student could be the first author on any publication resulting from this retrospective research study.<br />
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It is further recognized that investigators often employ research staff members (e.g., nurse coordinators, research assistants or associates) who may be involved in accessing and recording the medical record information as part of their ordinary job responsibilities. UPMC policies specify that these research staff members are considered members of the UPMC to the extent that they are performing services for P.I.s who are UPMC staff members or who have been granted UPMC privileges. Thus, research coordinators or other research staff may have access to, and may record, medical record information, provided that the P.I. of the research study is a UPMC staff member or UPMC privileged professional who provides related care, or is in the position to provide related care, to the respective patient population.<br />
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Regardless of who is involved in accessing and recording the medical information, the P.I. of the research study is responsible, and will be held accountable, for ensuring the confidentiality of the patients’ medical record information.<br />
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If the protocol, study procedures, and the P.I. meet all three of these criteria, a medical record research exempt review form must be completed and submitted to the University IRB in advance of accessing medical record information for this retrospective research study. This exempt submission is necessary so as to obtain institutional concurrence that the proposed research meets the criteria for exemption from the Federal Policy regulations as specified under 45 CFR Part 46.101.b.4. <br />
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To ensure compliance with provisions of the HIPAA Privacy Rule, a new University IRB exempt application form for retrospective medical record research studies (limited to investigators with relevant patient care responsibilities) has been developed that includes a request for a waiver of HIPAA authorization.<br />
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The HIPAA Privacy Rule (46 CFR Part 160; Part 164 (subparts A,E) requires that any request for a waiver of HIPAA authorization address three specific criteria. Each criterion is listed below, along with examples of appropriate model justifications for each.<br />
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Criterion 1: “The use or disclosure of protected health information involves no more than a minimal risk to the privacy of individuals based on (a) an adequate plan to protect the identifiers from improper use and disclosure; (b) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the conduct of the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (c) adequate written assurances that the protected health information will not be reused or disclosed to any other person or entity, except as required by law, for authorized oversight of the research study, or for other research for which the use or disclosure of protected health information would be permitted by this subpart.”<br />
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Justification: This criterion is readily met by investigators insofar as the medical information will be recorded without patient identifiers (e.g., names, phone numbers, addresses, etc.) or linkage codes (e.g., social security numbers, medical record numbers, etc.). Thus, there is no collection of protected health information (i.e., identifiable medical record information) or any possibility of subsequent disclosure of protected health information. Furthermore, and consistent with this waiver request, the investigators who will access the protected health information also provide related care, or are in the position to provide that care, to these patients, thus minimizing privacy and confidentiality concerns.<br />
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Criterion 2: “The research could not practicably be conducted without the waiver or alteration.”<br />
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Justification: This criterion is met by investigators insofar as the patients, whose protected health information will be accessed under this waiver request, have not previously provided informed consent for this retrospective research activity and it is impractical to obtain consent from these individuals because they are no longer in the hospital and contacting them is precluded by the researcher’s inability to use patients’ identifiable contact information without their prior consent. Thus, obtaining the HIPAA authorization of these patients for the research use of their health information is impracticable. <br />
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Criterion 3: “The research could not practicably be conducted without access to and use of the protected health information.”<br />
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Justification: This criterion is met by the overall scientific design of the study which focuses on identifying and/or evaluating inter-relationships among various medical variables. Consistent with the “minimum necessary standard” of the HIPAA privacy rule, investigators will access and collect only the specific health information necessary to complete this research study. <br />
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The HIPAA Privacy Rule (45 CFR 164.512.i) gives individuals the right to receive an accounting of certain disclosures of protected health information made by a covered entity. It also allows for a simplified accounting of disclosures of protected health information for research purposes, when at least 50 patient records are reviewed as part of the research activity. Because this simplified accounting procedure permits covered entities to provide individuals with a list of all protocols for which the patient’s protected health information may have been disclosed, the IRB will provide UPMC with a listing of each IRB protocol approved with a waiver of HIPAA authorization. This listing will include the title of the protocol, the researcher’s name, and the researcher’s contact information. <br />
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The following IRB Application Form, available on the Exempt Page of the IRB website (www.irb.pitt.edu) should be used: “Medical Record Review by Investigator with Patient Care Responsibilities”<br />
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B. Use of a Certified Honest Broker System<br />
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If the P.I. of the retrospective research study does not provide related care, or is not in the position to provide related care, to the patients whose medical records are being accessed, it is recommended that the investigator utilize the services of a University IRB certified honest broker system. The honest broker system, by definition, involves an individual or individuals (e.g., clinical clerk, nurse, IT staff) who would normally have access to the desired medical record information by virtue of her or his hospital responsibilities, and who is not involved as a listed investigator on the respective research study. The honest broker accesses the desired medical record information on behalf of the P.I. and provides the P.I. with an appropriately de-identified data set – either a completely de-identified data set (“HIPAA Safe-Harbor”) or a data set that includes patient-specific dates and/or geographical information (“Limited Data Set”). Use of an IRB-certified honest broker system ensures compliance with both the Federal Policy and HIPAA Privacy Rule regulations since no identifiable medical record information is being obtained or used directly by the investigators. Hence a waiver of the requirement for informed consent and/or HIPAA authorization is not necessary, and there is no need for the UPMC to track the use, on a patient-by-patient basis, of medical record information for research studies using this system. In addition, there is no requirement that all of the desired medical record information must be in existence at the time of IRB submission. That is, the honest broker can assign a code number to the data given to the investigator provided that the investigator does not have access to the information linking this code number to the identities of the respective patients. Using this code number, the investigator can request, through the honest broker, additional medical information corresponding to a given patient. From an IRB perspective, this type of application (where all data are not currently available for study) would meet criteria for ‘no human subjects’ involvement (45 CFR 46.102.f) because (a) the investigators have neither interacted nor intervened with these individuals for research purposes, and (b) the use of the honest broker ensures that the investigators will not obtain private identifiable information.<br />
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The following IRB Application Form, available on the Exempt Page of the IRB website (www.irb.pitt.edu) should be used: “Medical Record Review with Honest Broker”<br />
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C. Request for IRB Approval of a Waiver of Informed Consent/HIPAA Authorization<br />
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It is recognized that there may be situations in which investigators conducting retrospective medical record research need to collect information that includes patient identifiers (e.g., to link patient information obtained from multiple databases; to link existing patient information with new patient information) and do not have access to, or wish to use, an IRB-certified honest broker system. In accordance with the Federal Policy regulations and HIPAA Privacy Rule, the acquisition or use of identifiable medical record information for research requires both the written informed consent and HIPAA authorization of the involved patients, or University IRB approval of a waiver of both of these requirements. <br />
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The Federal Policy criteria (45 CFR 46.116.d) that must be addressed and justified (i.e., in the corresponding research protocol) in order for the University IRB to grant a waiver of informed consent are as follows:<br />
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(1) The research involves no more than minimal risk to the subjects<br />
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(2) The waiver of consent will not adversely affect the rights and welfare of the subjects<br />
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(3) The research could not practicably be carried out without the waiver<br />
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Regarding the second of these criteria, the University IRB has minimal concerns that the privacy and confidentiality rights of the involved patients are being adversely affected if the P.I. of the research study is a UPMC staff member and/or has been granted UPMC privileges and provides related care to these patients, or is in the position to provide related care to these patients. That is, by virtue of his or her patient care responsibilities, the P.I. would already be permitted to access the patients’ medical care information. As outlined above, the University IRB would also permit health professional students and research coordinators to access and obtain identifiable medical record information under the oversight and responsibility of such a P.I. The corresponding IRB application must address, and provide justifications for, each of the Federal Policy and HIPAA Privacy Rule criteria for granting a waiver of informed consent/HIPAA authorization. The University IRB web-site (HIPAA Page) currently incorporates a “Model Request for a Waiver of the Requirements to Obtain Informed Consent/HIPAA Authorization to Access, Record, and Use Protected Health Information/Identifiable Medical Record Information for a Retrospective Research Study: Principal Investigator Provides Care to the Respective Patients” (http://www.irb.pitt.edu/hipaa/waiver_835.pdf) Applicable P.I.s of retrospective medical record research studies need to simply incorporate the waiver criteria and model justifications into their IRB application. Since the University IRB has pre-approved the model justifications for the waiver criteria under this circumstance (i.e., the P.I. provides care to the respective patients), the application can be reviewed administratively (i.e., “expedited” review) and does not require consideration at a convened meeting of an IRB committee.<br />
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If the P.I. of the retrospective medical record research study does not provide related care to the respective patients, there are obvious concerns that investigator access to, and the recording of, patients’ identifiable medical record information may adversely affect the patients’ rights to privacy and confidentiality of this information. Thus, in this situation, the P.I. must address, in the corresponding IRB application, each of the Federal Policy and HIPAA (see above) criteria for granting a waiver of informed consent/ HIPAA authorization and must provide clear and thorough justifications regarding the applicability of these criteria to the proposed research. Since the University IRB holds informed consent as a primary principle governing the ethical conduct of human subject research, all such requests<a href="http://medical-record.blogspot.com/">http://medical-record.blogspot.com/</a> for a waiver of informed consent/HIPAA authorization will require review and approval by a convened IRB committee (i.e., “full board” IRB review). <br />
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This guidance was prepared under the direction of Christopher Ryan, working closely with IRB staff, and was approved by the University of Pittsburgh IRB Executive Committee on 18. February 2005. Please note that the focus of this guidance is limited solely to retrospective medical record reviews for research purposes. </div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-78424343399476565172011-05-26T08:58:00.000-07:002011-05-26T08:58:20.239-07:00STANDARD OPERATING PROCEDURES MEDICAL RECORD AUDIT<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:EnableOpenTypeKerning/> <w:DontFlipMirrorIndents/> <w:OverrideTableStyleHps/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
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<div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">1.<span> </span>INTRODUCTION</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">1.1.1.<span> </span>This standard operating procedure (SOP) describes the policy and procedure in <span> </span>the performance of a Medical Record Audit (MRA) for the Office of Human <span></span>Research Protection (OHRP) at the Medical College of Georgia (MCG) Health <span></span>System. A MRA may be performed on the medical record of any research subject <span></span>receiving a test article.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">2.<span> </span>OBJECTIVE</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">2.1.1.<span> </span>The objective of this SOP is to describe the procedures used in performing the <span> </span>MRA.<span> </span></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">3.<span> </span>SCOPE</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">3.1.1.<span> </span>This policy and procedure applies to all MRA’s performed by the OHRP. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">4.<span> </span>PROCEDURES</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.1.<span> </span>The CTA will contact the Investigational Pharmacist via telephone or e-mail to request a list of randomly selected research study subject names including the study subjects’ medical record numbers. The Investigational Pharmacist will either fax or email the list to the CTA. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.2.<span> </span>Once the CTA receives the list from the Investigational Pharmacist, the CTA will then access the electronic medical record (EMR) to locate the required documents. If the document(s) cannot be located in the EMR, then the CTA will contact the Health Information Management Services (HIMS) Technician and arrange a mutually convenient time for the CTA to review the hard copy medical record.<span> </span>In compliance with MCGHI policies, the audit of the research subjects’ hard copy medical record will take place in the HIMS area.<span> </span></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.<span> </span>In compliance with federal regulations and institutional policies the medical <span></span>records (e.g., EMR and hard copy) are assessed using the following standards:</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.1.<span> </span>Research Study Alert (RSA) or Study Alert located in the medical record.<span> </span>The RSA must be completed and submitted to HIMS for scanning into the EMR and <span></span>filing in the research subject’s hard copy medical record.<span> </span>A RSA is required if <span> </span>more than one research related study visit is required and/or the research subject <span></span>is hospitalized.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.2.<span> </span>Signed and dated copy of the applicable consent document located in the research subject’s medical record as per current MCG Health System Policies and <span></span>Procedures.<span> </span>the research informed consent documents are reviewed in <span> </span>accordance with OHRP SOP Informed Consent:<span> </span>Documentation of Process.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.3.<span> </span>Documentation of the research subject’s voluntary participation in the progress <span> </span>notes prior to the initiation of any study specific procedure(s) per current OHRP <span></span>SOPS. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.4.<span> </span>Documentation of study visits reported as such in the progress reports per current <span></span>OHRP SOPS.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.5.<span> </span>Documentation of the research subject’s continuing informed consent at each and <span></span>every study visit per current OHRP SOPS.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.6.<span> </span>An electronic report is generated that addresses the standards found and standards <span></span>not found. The original report is sent to the Principal Investigator (PI) via email. <span></span>The PI will be requested to provide clarification including a plan of corrective <span> </span>action to eliminate the potential for this problem reoccurring in the future. The <span></span>timeline given to the PI for responding is generally thirty (30) days from the date <span></span>of the findings letter. A copy of the findings letter is sent to the Study <span></span>Coordinator, Investigational Pharmacist, and a copy is provided to the IRB.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.7.<span> </span>Prior to sending the MRA Findings Report to the PI, the CTA will contact the PI and/or Study Coordinator by phone or e-mail to explain the process behind the <span></span>MRA.<span> </span>This contact provides an opportunity for the site to give feedback and to <span></span>be given guidance as to how to respond to the MRA.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.3.8.<span> </span>The results of a MRA may result in a “for cause” review of the study.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">5.<span> </span>REFERENCES/DOCUMENTATION</span></b></div><ul><li><span style="font-size: 12pt; line-height: 150%;">Medical College of Georgia Policies and Procedures</span></li>
<li><span style="font-size: 12pt; line-height: 150%;">MCG Health, Inc. Policies and Procedures</span></li>
<li><span style="font-size: 12pt; line-height: 150%;">http://hi.mcg.edu/aboutus/PDFPolicies/16_51.pdf</span></li>
<li><span style="font-size: 12pt; line-height: 150%;"><span></span>http://hi.mcg.edu/aboutus/policies/PDFPolicies/16_51.pdf</span></li>
<li><span style="font-size: 12pt; line-height: 150%;">Human Assurance Committee Policies and Procedures</span></li>
<li><span style="font-size: 12pt; line-height: 150%;">International Conference on Harmonization Good Clinical Practices Guidelines</span></li>
<li><span style="font-size: 12pt; line-height: 150%;">Food and Drug Administration Title 21 Part 50 Regulations</span></li>
<li><span style="font-size: 12pt; line-height: 150%;"><span></span><span></span>DHHS Office for Human Research Protections Regulations</span></li>
<li><span style="font-size: 12pt; line-height: 150%;">Clinical Research Standard Operating Procedures for MCG Health System</span></li>
</ul>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com1tag:blogger.com,1999:blog-531358123458879241.post-31643885035693882782011-05-26T08:53:00.001-07:002011-05-26T08:53:58.327-07:00DEPLOYED MEDICAL RECORD REQUEST INSTRUCTIONS<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:EnableOpenTypeKerning/> <w:DontFlipMirrorIndents/> <w:OverrideTableStyleHps/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
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<div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">DEPLOYED MEDICAL RECORD REQUEST INSTRUCTIONS</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">DD 2870 - Authorization for disclosure of medical or dental information, Dec. 2003</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">In order to facilitate the release of medical records, PASBA will follow this procedure:</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">Requesting a copy of the medical record</span></b></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -22.5pt;"><span style="font-size: 12pt; line-height: 150%;"><span>1.<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">PASBA will first verify if the medical record is in their possession. </span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -22.5pt;"><span style="font-size: 12pt; line-height: 150%;"><span>2.<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">If the record is in PASBA's custody, the requestor must complete DD Form 2870 (Authorization for Disclosure of Medical or Dental Information) and have the Service Member sign the form authorizing release of medical information. The requestor must provide detailed information describing specifically what information is being requested and why that information is needed, (i.e. UCMJ, Medical Board Processing, Separation Processing), particularly if the Service Member refuses to sign the request.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">In addition, specify exactly what episode of care the request is for. </span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>3.<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Once PASBA receives the signed authorization form, the PASBA Information Assurance (IA) Coordinator will review and verify the authenticity of the request and identity of the requestor as the patient owner of the record. After all requirements are fulfilled, the IA coordinator will approve to copy the record. PASBA will duplicate the medical record and mail the duplicate to the Service Member. A copy of DD Form 2870 will be placed in the Service Member's medical record documenting this action. </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>4.<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">The Requestor may be directed to contact NPRC in the event that the Medical Record has been retired. The Requestor may also be directed to the military treatment facility they were seen at in theater if PASBA has no record of receiving the medical record. </span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>5.<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Ft. Sam Houston SJA will review all medical records request from outside entities. Once SJA has approved this request, PASBA will duplicate the medical record and mail the duplicate to the requesting party. A copy of DD Form 2870 will be placed in the Service Member's medical record documenting this action. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">Purpose</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">PASBA receives all Inpatient Records from deployed medical units that do not have access to the Composite Health Care System (CHCS) once that unit returns from theater. PASBA reviews, performs data quality checks, codes, enters the record information into a number of databases and then forwards them to the National Personnel Records Center (NPRC) in St. Louis, Missouri for retirement. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">AR 40-66</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Army Regulation 40-66, Chapter 2 explains DA policies and procedures governing the release of medical information or medical records pertaining to individual patients. DA policy mandates that the confidentiality of patient medical information and medical records be protected to the fullest extent. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">Procedure</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">There may be instances when the patient or other agency (Staff Judge Advocate (SJA) Officer, soldier's Commander, MTF's Case Worker, etc.) requires copies of the medical records from deployments. Because the inpatient record is only at PASBA for a short time, there is a possibility the record may not be at PASBA when the request is made. PASBA will follow the above stated procedure (Requesting a copy of the medical record).</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">For requests, problems, or assistance contact:</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Information Assurance Coordinator, (210) 221-1414 DSN: 471</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">E-Mail Address: Record.Request@pasba2.amedd.army.mil</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Fax Num. 221-0263 DSN 471 </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">To suggest corrective action, Deputy Director, PASBA, (210) 295-9507 DSN: 421</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">E-Mail Address: Record.Request@pasba2.amedd.army.mil</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Fax Num. 221-0579 DSN 471 </span></div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-91569392494380815882011-05-26T08:50:00.001-07:002011-05-26T08:50:41.879-07:00MEDICAL RECORD AND DATABASE REVIEW REQUESTS<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:EnableOpenTypeKerning/> <w:DontFlipMirrorIndents/> <w:OverrideTableStyleHps/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
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<div class="MsoNormal" style="line-height: 150%; text-align: justify;">Policy</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; text-align: justify; text-indent: -0.25in;"><span style="font-family: Symbol;"><span>·<span style="font: 7pt "Times New Roman";"> </span></span></span>All retrospective medical record reviews and database requests that are performed for research purposes require review by the Committee on Clinical Investigation (CCI). </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; text-align: justify; text-indent: -0.25in;"><span style="font-family: Symbol;"><span>·<span style="font: 7pt "Times New Roman";"> </span></span></span>A specialized protocol application has been developed<span> </span>for retrospective medical record review and database requests for research purposes.<span> </span>The form requests the following information:<span> </span>who will perform the review; the purpose of the review; who will have access to the information; what the information will be used for; and the steps that will be taken to protect confidentiality.<span> </span>Information that is required to assure compliance with HIPAA regulations is also requested.<span> </span>In addition, the form requests the information needed to determine whether activity constitutes research with human subjects, whether it may be exempt from review or whether expedited review is required.<span> </span>Information is also collected to determine whether informed consent requirements may be waived under 45 CFR 46.116(d) or 45 CFR 46.117. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">Purpose</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">To identify the medical record reviews and database requests that are subject to CCI review, and to provide guidelines for the conduct of this review.</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">Procedures</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span><span>1.<span style="font: 7pt "Times New Roman";"> </span></span></span>Children’s Hospital has in place a simplified CCI review process for research that involves only the retrospective collection of data from medical records, computer databases, radiographs, and any other hospital-based records that exist for purposes other than research (e.g., quality improvement records). This form may also be used when investigator’s are obtaining records from other institutions for analysis purposes.</div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span><span>2.<span style="font: 7pt "Times New Roman";"> </span></span></span>The required CCI review applies to all research-related medical record reviews and database requests for research, regardless of whether the investigator wishes to maintain an identifier or a link to an identifier. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span><span>3.<span style="font: 7pt "Times New Roman";"> </span></span></span>If a protocol involves interaction with a subject, requires informed consent or requests information from physicians outside of Children's Hospital, a full CCI protocol application is required.<span> </span>If the research involves only the retrospective review of information contained in a medical record, hospital record, or computer database, a specialized form may be completed.<span> </span>Because X-rays and radiograph films are considered a part of the medical record, the same procedures apply.</div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span><span>4.<span style="font: 7pt "Times New Roman";"> </span></span></span>Investigator’s are asked to<span> </span>submit the special application form to the Clinical Investigation Office for review and approval.<span> </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span><span>5.<span style="font: 7pt "Times New Roman";"> </span></span></span>The type of information under review, where and how the data will be stored, who will have access to it, who is responsible for maintaining it, and the steps taken to maintain confidentiality will be considered. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span><span>6.<span style="font: 7pt "Times New Roman";"> </span></span></span>The Director of Clinical Research Compliance or Manager , reviews the form and clarifies any remaining issues with the investigator.<span> </span>A determination is made as to whether the activity constitutes human subject research, whether the activity is exempt or whether expedited review is appropriate. If the activity is determined to be expeditable, the Director of Clinical Research Compliance or<span> </span>Manager, as voting members of the IRB,<span> </span>may approve the request. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span><span>7.<span style="font: 7pt "Times New Roman";"> </span></span></span>Once review is complete, the request is approved by the Director of Clinical Research Compliance or Manager, and the investigator is notified. The approval indicates whether the request was determined to be non human subject research, exempt or expedited. Non human subject research will not require any additional follow-up. Exemptions will follow the policy and procedures for “Exemptions”. </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span><span>8.<span style="font: 7pt "Times New Roman";"> </span></span></span>For those activities that are determined to be expeditable, approval is valid for one year period. Investigators are sent notification two months prior to expiration and are asked to complete a continuing review form if the research is to continue. These forms are reviewed and approved by the Director of Clinical Research Compliance or Manager.<span> </span></div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-54486972683912490632011-05-26T08:43:00.001-07:002011-05-26T08:43:56.946-07:00ACCESS TO MEDICAL RECORDS<!--[if gte mso 9]><xml> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:EnableOpenTypeKerning/> <w:DontFlipMirrorIndents/> <w:OverrideTableStyleHps/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
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<div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">1.<span> </span>What is a Medical Record?</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">At common law the position is that “the person who makes the record owns the record.” Breen v Williams</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">However, the question arises as to what information makes up the medical record. </span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">The AMA endorses the following guidelines on patient’s access to records concerning their medical treatment:</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>“The patient has a right to be informed of all relevant factual information contained <span> </span>in the medical record, but all deductive opinion therein recorded remains the <span> </span>intellectual property of the doctor or doctors contributing to, or recognised <span> </span>employing hospital or other organisation maintaining the record…</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>On request , the patient should be informed of any or all content of the following <span> </span>sections of the medical record:</span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">History;</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Physical examination findings;</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Investigation results;</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Diagnosis</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Proposed management plan.”</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -22.5pt;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">There is a distinction between the right of the patient to access factual information regarding treatment and opinions of medical practitioners in the course of treatment: Breen v Williams per Gummow J.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">2.<span> </span>Policy Considerations for/against Access</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Arguments for usually deal with the idea of patient autonomy that is the patient has a right to know and have available at their disposal all information relating to their health so as to ensure they make informed decisions as to future treatment</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 22.5pt; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">On the other hand, medical professionals assert access may breach confidences; they may stop taking notes altogether if they knew patients could access them; </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b><span style="font-size: 12pt; line-height: 150%;">3.<span> </span>General Rule on Access</span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">The High Court of Australia in a unanimous decision held that there is no general right of access to medical records: Breen v Williams.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Breen v Williams (1996) 186 CLR 71</span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0.25in; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Mrs B had breast implants which were subsequently found to have leaked.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.25in; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">In order to participate in a class action against the US manufacturers, Mrs B req’d copies of her medical records.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.25in; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">She sought from Dr W (respondent) her records and he refused.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.25in; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Later he wrote a letter saying he would be willing to provide her with a medical report of things like her history, diagnosis, investigation results, advice and treatment but not his handwritten notes. She refused this offer.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.25in; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Mrs B went on to the Cts to seek a declaration that she had a right to examine and access her medical records. </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.25in; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">High Court dismissed.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.25in; text-align: justify; text-indent: -0.25in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Mrs B argued that her right to access her medical records arose from four sources:</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">A patient’s proprietary right/interest in the information contained in the records;</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">An implied term of the K between doctor-patient; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">A fiduciary relationship between doctor-patient; and</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">A general “right to know”</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Proprietary right/interest</span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>-<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Brennan CJ, Dawson, Toohey, Gaudron, McHugh and Gummow JJ</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Documents prepared by a professional person to assist the professional to perform his/her duty are not property of the lay client; they remain the property of the professional.</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">That property right entitles the doctor to refuse other person access to the records.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Implied term in K</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">-<span> </span>Brennan CJ</span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">In the absence of a special K between doctor-patient, doctor undertakes by the contract between them to advise and treat the patient with reasonable care and skill.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">No term implied that doctor act in “best interests” of patient terms limited to subject matter of K, that is, benefiting health of patient.</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">No term implied if K effective without it.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">-<span> </span>Dawson and Toohey JJ</span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Primary obligation under K was to use reasonable skill and care in treating and advising Mrs B. </span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Not necessary for reasonable/effective performance of that obligation to give Mrs B access to medical records.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">-<span> </span>Gaudron and McHugh JJ</span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Distinction between terms implied in fact and in law.</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Mrs B argued an implication by law that doctor act in “best interests” of patient however although a relevant consideration, doctor’s primary duty owed is to exercise reasonable skill and care in provision of professional advice and treatment.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Fiduciary relationship</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">- <span> </span>Brennan CJ, Dawson, Toohey, Gaudron, McHugh and Gummow JJ</span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">No definitive answer to what is a fiduciary relationship depends on nature of relationship and facts of the case</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Although duties of fiduciary nature may be imposed on doctor, doesn’t cover entire relationship.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">No fiduciary relationship with respect to access to medical records</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Generally relationship not fiduciary in nature</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Access to factual information</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">- Brennan CJ highlighted that information with respect to a patient’s history, condition or treatment etc, must be disclosed by the doctor when:</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(i)<span> </span>refusal to make the disclosure requested might prejudice the general health <span> </span>of the patient; </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(ii)<span> </span>the refusal for disclosure is reasonable having regard to all circumstances; <span> </span>and</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(iii)<span> </span>reasonable reward for the service of disclosure is tendered or assured</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">But the Canadian position as stated by La Forest J in McInerney v MacDonald in the Canadian Supreme Ct differs.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Canadian position holds that a patient is entitled to reasonable access to examine and copy the doctors records.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">This was founded on the grounds of a fiduciary relationship between doctor-patient in that it was the duty of the doctor to act with “utmost good faith and loyalty.”</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">La Forest J in McInerney v MacDonald reached the following conclusion:</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>“Information about oneself revealed to a doctor in a professional capacity remains, in a <span> </span>fundamental sense, one’s own. The doctor’s position is one of trust and confidence. The <span> </span>information conveyed is held in a fashion somewhat akin to a trust. While the doctor is the <span> </span>owner of the actual record, the information is to be used by the physician for the benefit of <span> </span>the patient. The confiding of the information to the physician for medical purposes fives rise <span> </span>to an expectations that the patient’s interests in and control of the information will continue.”</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">However the Australian High Ct in Breen v Williams emphatically rejected this proposition as not being the law of Australia.</span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Dawson and Toohey JJ stated that “there is no foundation in either principle or authority in this country” as such a duty of utmost good faith and loyalty “hardly fits with the undoubted duty of a doctor in this country.”</span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0.75in; text-align: justify; text-indent: -0.5in;"><span style="font-size: 12pt; line-height: 150%;"><span>•<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 12pt; line-height: 150%;">Gaudron and McHugh JJ said that in Australia “it is not possible to regard the doctor-patient relationship as one in which the doctor is under a general duty to act<span> </span>with utmost good faith and loyalty.”</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.<span> </span>Exceptions to General Rule</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">•<span> </span>There are however certain exceptions to the general rule of no access.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">•<span> </span>The major exceptions are found under the provisions of the Freedom of Information Act 1992 (Qld) and the Privacy Act 1988 (Cth).</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">4.1<span> </span>Freedom of Information Act 1992 (Qld)</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(i)<span> </span>SCOPE</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">•<span> </span>Under the FOI scheme, a person has a legally enforceable right to be given access to documents and records of an agency that is directly/indirectly supported by Govt funds.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">•<span> </span>Therefore applies to:</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">-<span> </span>govt dept’s, agencies etc</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">-<span> </span>only in public sector (doesn’t extend to private health care facilities.)</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(ii)<span> </span>GENERAL</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Section 21- Right of access</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Subject to this Act, a person has a legally enforceable right to be given</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">access under this Act to—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(a) <span> </span>documents of an agency; and</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(b) <span> </span>official documents of a Minister</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(iii)<span> </span>EXEMPTIONS</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">•<span> </span>There are certain documents to which access may be refused: s.22</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Section 22 - Documents to which access may be refused</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">An agency or Minister may refuse access under this Act to—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(a) <span> </span>a document that is reasonably open to public access (whether or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>not as part of a public register) under another enactment, whether</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>or not the access is subject to a fee or charge; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(b) <span> </span>a document that is reasonably available for purchase by members of <span> </span>the community under arrangements made by an agency; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(c)<span> </span>a document that is reasonably available for public inspection under <span> </span>the Public Records Act 2002 or in a public library; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(d)<span> </span>a document that—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(i) <span> </span>is stored for preservation or safe custody in the <span> </span><span> </span>Queensland State Archives; and</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(ii)<span> </span>is a copy of a document of an agency; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(e) <span> </span>adoption records maintained under the Adoption of Children Act <span> </span>1964.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">•<span> </span>There are also certain categories under which there are exempt matters</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Section 44 - Matter affecting personal affairs</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(1) <span> </span>Matter is exempt matter if its disclosure would disclose information concerning the <span> </span>personal affairs of a person, whether living or dead, unless its disclosure would, on <span> </span>balance, be in the public interest.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(2) <span> </span>Matter is not exempt under subsection (1) merely because it relates to information <span> </span>concerning the personal affairs of the person by whom, or on whose behalf, an <span> </span>application for <span> </span>access to a document containing the matter is being made.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(3) <span> </span>If—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(a) <span> </span>an application is made to an agency or Minister for access to a <span> </span><span> </span>document of the agency or an official document of the Minister <span> </span>that contains information of a medical or psychiatric nature <span> </span>concerning the person making the application; and</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(b) <span> </span>it appears to the principal officer of the agency or the Minister <span> </span>that the disclosure of the information to the person might be <span> </span>prejudicial to the physical or mental health or wellbeing of the <span> </span>person; </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>the principal officer or Minister may direct that access to the document is not to be <span> </span>given to <span> </span>the person but is to be given instead to a medical practitioner nominated by <span> </span>the person and approved by the principal officer or Minister.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(4) <span> </span>An agency or Minister may appoint a medical practitioner to make a decision under <span> </span>subsection on behalf of the agency or Minister.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Section 46- Matter communicated in confidence</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(1) <span> </span>Matter is exempt if—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(a) <span> </span>its disclosure would found an action for breach of confidence; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(b) <span> </span>it consists of information of a confidential nature that was <span> </span><span> </span>communicated in <span> </span>confidence, the disclosure of which could <span> </span>reasonably be expected to prejudice the future supply of such <span> </span>information, unless its disclosure would, on balance, be in the public <span> </span>interest.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(2) <span> </span>Subsection (1) does not apply to matter of a kind mentioned in section 41(1)(a) unless <span> </span>its disclosure would found an action for breach of confidence owed to a person or <span> </span>body other than—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(a) a person in the capacity of—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(i) a Minister; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(ii) a member of the staff of, or a consultant to, a Minister; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(iii) an officer of an agency; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(b) the State or an agency.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Section 42- Matter relating to law enforcement or public safety</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(1)<span> </span> Matter is exempt matter if its disclosure could reasonably be expected to—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(a) <span> </span>prejudice the investigation of a contravention or possible <span> </span><span> </span>contravention of the law (including revenue law) in a particular case; <span> </span>or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(b) <span> </span>enable the existence or identity of a confidential source of <span> </span><span> </span>information, in relation to the enforcement or administration of the <span> </span>law, to be ascertained; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(c) <span> </span>endanger a person’s life or physical safety; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(d) <span> </span>prejudice a person’s fair trial or the impartial adjudication of a <span> </span><span> </span>case; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(e) <span> </span>prejudice the effectiveness of a lawful method or procedure for <span> </span><span> </span>preventing, detecting, investigating or dealing with a contravention <span> </span>or possible contravention of the law (including</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>revenue law); or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(f) <span> </span>prejudice the maintenance or enforcement of a lawful method or <span> </span><span> </span>procedure for protecting public safety; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(g) <span> </span>endanger the security of a building, structure or vehicle; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(h) <span> </span>prejudice a system or procedure for the protection of persons,</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>property or environment; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(i) <span> </span>facilitate a person’s escape from lawful custody; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(j) <span> </span>prejudice the wellbeing of a cultural or natural resource or the <span> </span><span> </span>habitat of animals or plants.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(1A) <span> </span>Matter is also exempt matter if—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(a) <span> </span>it consists of information given in the course of an investigation of a <span> </span><span> </span>contravention or possible contravention of the law (including <span> </span>revenue law); and</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(b) <span> </span>the information was given under compulsion under an Act that <span> </span><span> </span>abrogated the privilege against self-incrimination.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(2) <span> </span>Matter is not exempt under subsection (1) if—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(a) <span> </span>it consists of—</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span><span> </span>(i) <span> </span>matter revealing that the scope of a law <span> </span><span> </span>enforcement investigation has exceeded the limits <span> </span>imposed by law; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(ii) <span> </span>matter containing a general outline of the <span> </span><span> </span>structure of a program adopted by an agency for <span> </span>dealing with a contravention or possible <span> </span>contravention of the law; or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(iii) <span> </span>a report on the degree of success achieved in a <span> </span><span> </span>program adopted by an agency for dealing with a <span> </span><span> </span>contravention or possible contravention of the law; <span> </span>or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(iv) <span> </span>a report prepared in the course of a routine law <span> </span><span> </span>enforcement inspection or investigation by an <span> </span>agency whose functions include that of enforcing <span> </span>the law (other than the criminal</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>law or the law relating to misconduct under the <span> </span><span> </span>Crime and Misconduct Act 2001); or</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(v) <span> </span>a report on a law enforcement investigation that <span> </span><span> </span>has already been disclosed to the person or body <span> </span>the subject of the investigation; and</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"><span> </span>(3) <span> </span>A certificate signed by the Minister stating that a specified matter would, if it <span> </span>existed, be exempt matter mentioned in subsection (1), but not matter mentioned in <span> </span>subsection (2), establishes, subject to part 5, that, if the matter exists, it is exempt <span> </span>matter under this section.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(4) <span> </span>A reference in this section to a contravention or possible contravention of the law <span> </span>includes a reference to misconduct or possible misconduct under the Crime and <span> </span>Misconduct Act 2001.</span></div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-73857192281562625782011-05-24T10:17:00.000-07:002011-05-24T13:12:24.461-07:0070 MEDICAL RECORDS<div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">19a-14-40. Medical records, definition, purpose </span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">The purpose of a medical record is to provide a vehicle for: documenting actions taken in patient management; documenting patient progress; providing meaningful medical information to other practitioners should the patient transfer to a new provider or should the provider be unavailable for some reason. A medical record shall include, but not be limited to, information sufficient to justify any diagnosis and treatment rendered, dates of treatment, actions taken by non-licensed persons when ordered or authorized by the provider; doctors' orders, nurses notes and charts, birth certificate work-sheets, and any other diagnostic data or documents specified in the rules and regulations. All entries must be signed by the person responsible for them. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"> (Effective August 29, 1984.)</span><br />
<a name='more'></a><span style="font-size: 12pt; line-height: 150%;"> </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><a href="http://medical-record.blogspot.com/"><span style="font-size: 12pt; line-height: 150%;"> http://medical-record.blogspot.com/</span></a></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">19a-14-41. Professions involved </span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Each person licensed or certified pursuant to the following chapters and Acts shall maintain appropriate medical records of the assessment, diagnosis, and course of treatment provided each patient, and such medical records shall be kept for the period prescribed: chapters 334b, 370 thru 373, 375, 376, 378 thru 381, 383 thru 384, 388, 398, 399, and Public Acts 83-352 and 83-441. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"> (Effective August 29, 1984.) </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">19a-14-42. Retention schedule </span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Unless specified otherwise herein, all parts of a medical record shall be retained for a period of seven (7) years from the last date of treatment, or, upon the death of the patient, for three (3) years. </span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(a)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Pathology Slides, EEG and ECG Tracings must each be kept for seven (7) years. If an ECG is taken and the results are unchanged from a previous ECG, then only the most recent results need be retained. Reports on each of these must e kept for the duration of the medical record. </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(b)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Lab Reports and PKU Reports must be kept for at least five (5) years. Only positive (abnormal) lab results need be retained. </span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l1 level1 lfo1; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(c)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">X-Ray Films must be kept for three (3) years. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"> (Effective August 29, 1984.) </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">19a-14-43. Exceptions </span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Nothing in these regulations shall prevent a practitioner from retaining records longer than the prescribed minimum. When medical records for a patient are retained by a health care facility or organization, the individual practitioner shall not be required to maintain duplicate records and the retention schedules of the facility or organization shall apply to the records. If a claim of malpractice, unprofessional conduct, or negligence with respect to a particular patient has been made, or if litigation has been commenced, then all records for that patient must be retained until the matter is resolved. A consulting health care provider need not retain records if they are sent to the referring provider, who must retain them. If a patient requests his records to be transferred to another provider who then becomes the primary provider to the patient, then the first provider is no longer required to retain that patient's records. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"> (Effective August 29, 1984.) </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">19a-14-44. Discontinuance of practice </span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">Upon the death or retirement of a practitioner, it shall be the responsibility of the practitioner or surviving responsible relative or executor to inform patients. This must be done by placing a notice in a daily local newspaper published in the community which is the prime locus of the practice. This notice shall be no less than two columns wide and no less than two inches in height. The notice shall appear twice, seven days apart. In addition, an individual letter is to be sent to each patient seen within the three years preceding the date of discontinuance of the practice. Medical records of all patients must be retained for at least sixty days following both the public and private notice to patients. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;"> (Effective August 29, 1984.) </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">19a-14-50. Definitions </span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">For the purposes of these regulations, "Doctor" means either a physician licensed pursuant to Chapter 370 of the Connecticut General Statutes or an Optometrist licensed pursuant to Chapter 380 of the Connecticut General Statutes. </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">(Effective August 29, 1986.) </span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">19a-14-51. Optician record retention </span></b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: 12pt; line-height: 150%;">For each client fitted with prescription eyeglasses or prescribed contact lenses, a licensed optician shall keep a record. When prescription items are dispensed by a registered apprentice optician, the supervising licensed optician must verify the accuracy of all the data included in the client record and indicate this on the record. A client record shall contain the following: </span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-align: justify; text-indent: -21.8pt;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">(a)<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Prescription Eyewear Records shall include: </span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -16.9pt;"><span style="font-size: 12pt; line-height: 150%;">(1)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Doctor's prescription and date, including name of prescribing doctor; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -16.9pt;"><span style="font-size: 12pt; line-height: 150%;">(2)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Date of delivering said prescription, to include any duplication of existing lenses; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -16.9pt;"><span style="font-size: 12pt; line-height: 150%;">(3)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Facial measurements, to include but not be limited to: interpupillary measures; frame size determinations, including eye size, bridge size, temple length; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -16.9pt;"><span style="font-size: 12pt; line-height: 150%;">(4)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Name of frame provided; and </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -16.9pt;"><span style="font-size: 12pt; line-height: 150%;">(5)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Lens description to include: lens materials; placement of optical centers; lens tint; and, when applicable, multifocal type and placement of multifocal. </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-align: justify; text-indent: -21.8pt;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">(b)<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Contact Lenses Prefit </span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.85pt;"><span style="font-size: 12pt; line-height: 150%;">(1)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Prefitting record shall include: date of client visit; doctor's written prescription; doctor's keratometric measures if such measures are provided, and such other measures or observations which are properly within the optician's scope of practice as defined by Connecticut General Statutes Section 20-139; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.85pt;"><span style="font-size: 12pt; line-height: 150%;">(2)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Any information which would contraindicate the fitting of contact lenses; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.85pt;"><span style="font-size: 12pt; line-height: 150%;">(3)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">The date of the examining doctor's prescription; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.85pt;"><span style="font-size: 12pt; line-height: 150%;">(4)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">A prefitting biomicroscopic record of the external eye made by the doctor, if such is provided; and </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.85pt;"><span style="font-size: 12pt; line-height: 150%;">(5)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Any notice provided to the client regarding the length of time after which the prescription will not be refilled. </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-align: justify; text-indent: -21.8pt;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">(c)<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Contact Lens Dispensing Records on the dispensing of contact lenses shall include: </span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(1)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">All particular lens parameters including manufacturer; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(2)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Date of client instruction in handling and hygiene; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(3)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Visual acuity recorded with dispensed contact lenses as obtained by use of a standardized snellen-type chart; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(4)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">If performed, a summary of observations of the physical relationship between dispensed contact lens and cornea, including, but not limited to, biomicroscopic observations; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(5)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">A recommended wearing schedule; and </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.8pt;"><span style="font-size: 12pt; line-height: 150%;">(6)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">A summary of recommended follow-up. </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l0 level1 lfo2; text-align: justify; text-indent: -21.8pt;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">(d)<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Contact Lens Follow-up Records of visits subsequent to the actual dispensing of contact lenses shall include: </span></b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.25pt;"><span style="font-size: 12pt; line-height: 150%;">(1)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Date of each visit; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.25pt;"><span style="font-size: 12pt; line-height: 150%;">(2)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Client's current wearing schedule; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.25pt;"><span style="font-size: 12pt; line-height: 150%;">(3)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Visual acuity recorded with dispensed contact lenses, obtained by use of a standardized snellen-type chart; </span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.25pt;"><span style="font-size: 12pt; line-height: 150%;">(4)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">Date of next recommended visit; and </span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 42.55pt; mso-add-space: auto; mso-list: l0 level2 lfo2; text-align: justify; text-indent: -21.25pt;"><span style="font-size: 12pt; line-height: 150%;">(5)<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-size: 12pt; line-height: 150%;">A description of any perceived changes in visual acuity or obvious anomalies, and a record of any report made to the client or prescribing doctor. </span></div><span style="font-family: "Calibri","sans-serif"; font-size: 12pt; line-height: 115%;">(Effective August 29, 1986.) </span><br />
<a href="http://medical-record.blogspot.com/"><span style="font-family: "Calibri","sans-serif"; font-size: 12pt; line-height: 115%;">http://medical-record.blogspot.com/</span></a>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-10545752400526864272011-05-21T13:26:00.000-07:002011-05-24T13:13:32.389-07:00DOCUMENTATION CONTENTS OF THE MEDICAL RECORD<div class="MsoNormal" style="line-height: 150%; text-align: justify;">The medical record shall include, at a minimum, the following items (if applicable): </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"> A. Identification information, which include but are not limited to the following: </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"> Name. </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">1)<span style="font: 7pt "Times New Roman";"> </span>Address on admission. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">2)<span style="font: 7pt "Times New Roman";"> </span>Identification number (if applicable).<br />
<a name='more'></a> </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l3 level1 lfo2; tab-stops: 1.0cm; text-align: justify; text-indent: -18.0pt;"> 1.<span style="font: 7pt "Times New Roman";"> </span>Medicare. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l3 level1 lfo2; tab-stops: 1.0cm; text-align: justify; text-indent: -18.0pt;"> 2.<span style="font: 7pt "Times New Roman";"> </span>Medi-Cal. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l3 level1 lfo2; tab-stops: 1.0cm; text-align: justify; text-indent: -18.0pt;"> 3.<span style="font: 7pt "Times New Roman";"> </span>Hospital Number </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l3 level1 lfo2; tab-stops: 1.0cm; text-align: justify; text-indent: -18.0pt;"> 4.<span style="font: 7pt "Times New Roman";"> </span>Social Security Number. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">3)<span style="font: 7pt "Times New Roman";"> </span>Age. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">4)<span style="font: 7pt "Times New Roman";"> </span>Sex. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">5)<span style="font: 7pt "Times New Roman";"> </span>Marital status. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">6)<span style="font: 7pt "Times New Roman";"> </span>Legal status. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">7)<span style="font: 7pt "Times New Roman";"> </span>Mother’s Maiden name </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo3; tab-stops: 1.0cm; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;"> ·<span style="font: 7pt "Times New Roman";"> </span></span>Patient’s Mother’s maiden name </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo3; tab-stops: 1.0cm; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;"> ·<span style="font: 7pt "Times New Roman";"> </span></span>Place of Birth </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">8)<span style="font: 7pt "Times New Roman";"> </span>Legal Authorization for admission (if applicable). </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">9)<span style="font: 7pt "Times New Roman";"> </span>School Grade, if applicable </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">10)<span style="font: 7pt "Times New Roman";"> </span>Religious Preference. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; tab-stops: 1.0cm; text-align: justify; text-indent: -16.1pt;">11)<span style="font: 7pt "Times New Roman";"> </span>Date and time of admission (or arrival for outpatients). </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">12)<span style="font: 7pt "Times New Roman";"> </span>Date of time discharge (departure for outpatients). </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">13)<span style="font: 7pt "Times New Roman";"> </span>Name, address and telephone number of person or agency responsible for patient. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">14)<span style="font: 7pt "Times New Roman";"> </span>Name of patient's admitting/attending physician. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">15)<span style="font: 7pt "Times New Roman";"> </span>Initial diagnostic impression. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">16)<span style="font: 7pt "Times New Roman";"> </span>Discharge or final diagnosis and disposition. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">17)<span style="font: 7pt "Times New Roman";"> </span>Allergy records. </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">18)<span style="font: 7pt "Times New Roman";"> </span>Advance Directives (if applicable). </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">20) Medical History including, as appropriate: immunization record, screening tests, allergy record, nutritional evaluation, psychiatric, surgical and past medical history, social and family history, and for pediatric patients a neonatal history. </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">19)<span style="font: 7pt "Times New Roman";"> </span>Physical examination. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">20)<span style="font: 7pt "Times New Roman";"> </span>Consultation reports. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">21)<span style="font: 7pt "Times New Roman";"> </span>Orders including those for medication, treatment, prescriptions, diet orders, lab, radiology and other ancillary services. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">22)<span style="font: 7pt "Times New Roman";"> </span>Progress notes including current or working diagnosis (excluding psychotherapy notes). </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">23)<span style="font: 7pt "Times New Roman";"> </span>Nurses' notes, which shall include, but not be limited to, the following: </div><ol><li>Nursing assessment including nutritional, psychosocial and functional assessments. </li>
<li>Concise and accurate record of nursing care administered. </li>
<li><span style="font: 7pt "Times New Roman";"> </span>Record of pertinent observations including psychosocial and physical manifestations and relevant nursing interpretation of such observations. </li>
<li><span style="font: 7pt "Times New Roman";"></span>Name, dosage and time of administration of medications and treatment. Route of administration and site of injection shall be recorded if other than by oral administration. </li>
<li>Record of type of restraint and time of application and removal. </li>
<li><span style="font: 7pt "Times New Roman";"></span>Record of seclusion and time of application and removal. (NPH) </li>
</ol><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">24)<span style="font: 7pt "Times New Roman";"> </span>Graphic and vital sign sheet. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">25)<span style="font: 7pt "Times New Roman";"> </span>Results of all laboratory tests performed. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">26)<span style="font: 7pt "Times New Roman";"> </span>Results of all X-ray examinations performed. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">27)<span style="font: 7pt "Times New Roman";"> </span>Consent forms for care, treatment and research, when applicable. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">28)<span style="font: 7pt "Times New Roman";"> </span>Problem List (outpatient records only). </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">29)<span style="font: 7pt "Times New Roman";"> </span>Emergency Department record. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">30)<span style="font: 7pt "Times New Roman";"> </span>Anesthesia record including preoperative diagnosis, if anesthesia has been administered. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">31)<span style="font: 7pt "Times New Roman";"> </span>Operative and procedures report including preoperative and postoperative diagnosis, description of findings, technique used, and tissue removed or altered, if surgery was performed. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">32)<span style="font: 7pt "Times New Roman";"> </span>Pathology report, if tissue or body fluid was removed. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">33)<span style="font: 7pt "Times New Roman";"> </span>Written record of preoperative and postoperative instructions. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">34)<span style="font: 7pt "Times New Roman";"> </span>Labor record, if applicable. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">35)<span style="font: 7pt "Times New Roman";"> </span>Delivery record, if applicable. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">36)<span style="font: 7pt "Times New Roman";"> </span>Physical, Occupational and/or respiratory therapy assessments and treatment records, when applicable. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">37)<span style="font: 7pt "Times New Roman";"> </span>Patient/Family Education Plan (NPH Only) </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">38)<span style="font: 7pt "Times New Roman";"> </span>Clinical Data set from other providers. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">39)<span style="font: 7pt "Times New Roman";"> </span>Master Data Sets (as applicable to record type) including but not limited to : MDS (Skilled Nursing), OASIS (Home Health), IRF and PAI (Rehabilitation). </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">40)<span style="font: 7pt "Times New Roman";"> </span>Patient Photographs when used for identification or treatment. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">41)<span style="font: 7pt "Times New Roman";"> </span>Master Treatment Plan and Reassessment (NPH only). </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">42)<span style="font: 7pt "Times New Roman";"> </span>Discharge Instructions </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">43)<span style="font: 7pt "Times New Roman";"> </span>A discharge summary which shall briefly recapitulate the significant findings and events of the patient's hospitalization, final diagnoses, his/her condition on discharge and the recommendations and arrangements for future care. If applicable it shall include diet and self-care instructions. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">44)<span style="font: 7pt "Times New Roman";"> </span>Copies of letters to patients. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">45)<span style="font: 7pt "Times New Roman";"> </span>Email communications between the patients and the provider regarding the care and treatment of the patient. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">46)<span style="font: 7pt "Times New Roman";"> </span>Telephone Encounters. Documentation is required for telephone encounters with patients and/or their caregivers, or other care providers that: </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo5; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Provide new or renewal of prescription for medications </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo5; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Alter the current plan of care, including treatments and medications </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo5; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>Identify a new system or problem and provide a plan of care </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo5; text-align: justify; text-indent: -18.0pt;">4.<span style="font: 7pt "Times New Roman";"> </span>Provide home care advice for symptom/problem management </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo5; text-align: justify; text-indent: -18.0pt;">5.<span style="font: 7pt "Times New Roman";"> </span>Provide authorization for care </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; mso-list: l4 level1 lfo5; text-align: justify; text-indent: -18.0pt;">6.<span style="font: 7pt "Times New Roman";"> </span>Provides or reinforces patient education </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">Documentation should include the date and time of call, name of caller and relationship to patient (if different from patient), date and time of the response (or attempts to return call), the response given, and the signature and professional title of provider or clinic staff handling the call. </div><div class="MsoListParagraph" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level3 lfo1; text-align: justify; text-indent: -16.1pt;">47)<span style="font: 7pt "Times New Roman";"> </span>Primary Language<br />
<a href="http://medical-record.blogspot.com/%20">http://medical-record.blogspot.com/ </a></div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-61718792691153166552011-05-21T13:16:00.003-07:002011-05-24T13:14:10.772-07:00ENFORCEMENT, CORRECTIVE & DISCIPLINARY ACTIONS<div class="MsoNormal" style="line-height: 150%; text-align: justify;">Compliance with the above policy is monitored by UC__ Department of ________. Violations of any of the above policy will be reported to the appropriate supervising authority for potential disciplinary action, up to and including termination and/or restriction of privileges in accordance with UC__ Medical Staff ByLaws, and Human Resource / Personnel Policies. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
<a name='more'></a><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">RELATED POLICIES </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>Each UC may insert a list of related policies and forms or include the list as a separate Appendix, </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>Authorization for Release of Information; and Access to the medical record </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>Patient Requests for Record Amendment and Record Addendums </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>Auditing of access to medical records </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>“Notice of Privacy Practices”; and in other UC__ Privacy Policies and Procedures. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>“Authorization for Use/Disclosure of PHI” </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>Employee Access to Protected Health Information (“PHI”) </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>“Records Retention” </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>“Records Storage and Destruction </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;"><span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";"> </span></span>Verbal / Telephone Orders </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">APPROVAL </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"> REVISION HISTORY </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><b style="mso-bidi-font-weight: normal;"> REFERENCES </b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"> Health Insurance Portability and Accountability Act (HIPAA) Privacy & Security Rule, 45 CFR 160-164 </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">California Medical Information Act, California Civil Code Section 56 et seq. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">Medicare Conditions of Participation, 42 CFR Section 482.24 </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">Title 22 California Code of Regulations, Sections 70749, 70527, and 71549 </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">Business Records Exception, Federal Evidence 803(6) </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">California Code of Regulations, Title 22, Section 70751 </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">California Healthcare Association Manual – Authentication sections<br />
<a href="http://medical-record.blogspot.com/%20">http://medical-record.blogspot.com/ </a><br />
</div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-85236028075235434552011-05-21T13:14:00.001-07:002011-05-24T13:14:56.354-07:00DESIGNATION OF SECONDARY PATIENT INFORMATION<div class="MsoNormal" style="line-height: 150%; text-align: justify;">The following three categories of data contain secondary patient information and must be afforded the same level of confidentiality as the LMR, but are not considered part of the legal medical record. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">A. Patient-identifiable source data are data from which interpretations, summaries, notes, etc. are derived. They often are maintained at the department level in a separate location or database, and are retrievable only upon request. <br />
<a name='more'></a>Examples: </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Photographs for identification purposes </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Audio recordings of dictation notes or patient phone calls. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>Video recordings of an office visit, if taken for other than patient care purposes </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">Acknowledge that there may be older systems that do not have this capability. Future plans for all system to meet this minimum requirement. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">4.<span style="font: 7pt "Times New Roman";"> </span>Video recordings/pictures of a procedure, if taken for other than patient care purposes </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">5.<span style="font: 7pt "Times New Roman";"> </span>Video recordings of a telemedicine consultation </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">6.<span style="font: 7pt "Times New Roman";"> </span>Communication tools (i.e., Kardex, patient lists, work lists, administrative in-baskets messaging, sign out reports, FYI, drafts of notes, or summary reports prepared by clinicians, etc.) </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">7.<span style="font: 7pt "Times New Roman";"> </span>Protocols/clinical pathways, best practice alerts, and other knowledge sources. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">8.<span style="font: 7pt "Times New Roman";"> </span>A Patient’s personal health record provided by the patient to his or her care provider. </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; mso-list: l2 level1 lfo1; text-align: justify; text-indent: -18.0pt;">9.<span style="font: 7pt "Times New Roman";"> </span>Alerts, reminders, pop-ups and similar tools used as aides in the clinical decision making process.</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">The tools themselves are not considered part of the legal medical record. However, the associated documentation of subsequent actions taken by the provider, including the condition acted upon and the associated notes detailing the exam, are considered as component of the legal medical record. Similarly, any annotations, notes and results created by the provider as a result of the alert, reminder or pop-up are also considered part of the legal medical record. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">Some source data are not maintained once the data has been converted to text. Certain communication tools are part of workflow and are not maintained after patient's discharge. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">B. Administrative Data is patient-identifiable data used for administrative, regulatory, healthcare operations and payment purposes. Examples include but are not limited to: </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Authorization forms for release of information </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Correspondence concerning requests for records. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>Birth and death certificates. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">4.<span style="font: 7pt "Times New Roman";"> </span>Event history/audit trails. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">5.<span style="font: 7pt "Times New Roman";"> </span>Patient-identifiable abstracts in coding system. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">6.<span style="font: 7pt "Times New Roman";"> </span>Patient identifiable data reviewed for quality assurance or utilization management. </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">7.<span style="font: 7pt "Times New Roman";"> </span>Administrative reports. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">C. Derived Data consists of information aggregated or summarized from patient records so that there are no means to identify patients. Examples: </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Accreditation reports </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Best practice guidelines created from aggregate patient data. </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>ORYX reports, public health records and statistical reports. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">D. Draft Documents / Work in Progress. Electronic processes and workflow management require methods to manage work in progress. These work-in-progress documents often are available in the system as “draft documents, viewable to a limited number of users. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">They generally are not viewable to clinicians until the document is sent for final signature. Draft documents are not considered an official medical record document until it has been signed by an authorized signer.<br />
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</div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-11663262934287788522011-05-21T13:11:00.005-07:002011-05-24T13:15:35.754-07:00AUTHENTICATION OF ENTRIES<div class="MsoNormal" style="line-height: 150%; text-align: justify;">A. Electronic signatures must meet standards for: </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Data integrity to protect data from accidental or unauthorized change (for example “locking” of the entry so that once signed no further untracked changes can be made to the entry); </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Authentication to validate the correctness of the information and confirm the identity of the signer (for example requiring signer to authenticate with password or other mechanism); </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level2 lfo1; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>Non-repudiation to prevent the signer from denying that he or she signed the document (for example, public/private key architecture).<br />
<a name='more'></a> </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">At a minimum, the electronic signature must include the full name and either the credentials of the author or a unique identifier, and the date and time signed.* </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">B. Electronic signatures must be affixed only by that individual whose name is being affixed to the document and no other individual. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">C. Countersignatures or dual signatures must meet the same requirements, and are used as required by State law and Medical Staff Rules and Regulations. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">D. Initials may be used to authenticate entries on flow sheets or medication records, and the document must include a key to identify the individuals whose initials appear on the document. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">E. Rubber stamp signatures: Refer to Section VI (D). </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">F. Documents with multiple sections or completed by multiple individuals should include a signature area on the document for all applicable staff to sign and date. Staffs who have completed sections of a form should either indicate the sections they completed at the signature line or initial the sections they completed. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">G. No individual shall share electronic signature keys with any other individual. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">H. Macros & Checklists. Pre-printed forms, checklists, patient questionnaires, and word-processing macros can be used to supplement written or dictated notes. When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation, if the teaching physician adds it personally in a secured (password protected) system. In addition to the teaching physician’s macro, either the resident or the teaching physician must provide customized, patient specific information that is sufficient to support a medical necessity determination. The note in the record must sufficiently describe the specific services furnished to the specific patient on the specific date. It is insufficient documentation if both the resident and the teaching physician use macros which do not contain patient specific information. Medical record macros and checklists may be used to supplement provider written or dictated notes.<br />
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</div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-88337051733525416772011-05-21T13:09:00.001-07:002011-05-24T13:20:55.977-07:00CORRECTIONS AND AMENDMENTS TO RECORDS<div class="MsoNormal" style="line-height: 150%; text-align: justify;">When an error is made in a medical record entry, the original entry must not be obliterated, and the inaccurate information should still be accessible. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">The correction must indicate the reason for the correction, and the correction entry must be dated and signed by the person making the revision. Examples of reasons for incorrect entries may include “wrong patient,” etc. The contents of Medical Records must not otherwise be edited, altered, or removed. Patients may request a medical record amendment and/or a medical record addendum. (Refer to UC__ policy for handling patient requests for record amendment and record addendums.) <br />
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</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;"><b style="mso-bidi-font-weight: normal;">A.<span style="font: 7pt "Times New Roman";"> </span></b><b style="mso-bidi-font-weight: normal;">DOCUMENTS CREATED IN A PAPER FORMAT: </b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo7; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Do not place labels over the entries for correction of information. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo7; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>If information in a paper record must be corrected or revised, draw a line through the incorrect entry and annotate the record with the date and the reason for the revision noted, and signature of the person making the revision. </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; mso-list: l4 level1 lfo7; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>If the document was originally created in a paper format, and then scanned electronically, the electronic version must be corrected by printing the documentation, correcting as above in (2), and rescanning the document. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;"><b style="mso-bidi-font-weight: normal;">B.<span style="font: 7pt "Times New Roman";"> </span></b><b style="mso-bidi-font-weight: normal;">DOCUMENTS THAT ARE CREATED ELECTRONICALLY MUST BE CORRECTED BY ONE OF THE FOLLOWING MECHANISMS: </b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level2 lfo6; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Adding an addendum to the electronic document indicating the corrected information, the identity of the individual who created the addendum, the date created, and the electronic signature of the individual making the addendum. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level2 lfo6; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Preliminary versions of transcribed documents may be edited by the author prior to signing. A transcription analyst may also make changes when a non-clinical error is discovered prior to signing (i.e., wrong work type, wrong date, wrong attending assigned). If the preliminary document is visible to providers other than the author, then this document needs to be part of the legal health record. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level2 lfo6; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>Once a transcribed document is final, it can only be corrected in the form of an addendum affixed to the final copy as indicated above. Examples of documentation errors that are corrected by addendum include: wrong date, location, duplicate documents, incomplete documents, or other errors. The amended version must be reviewed and signed by the provider. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level2 lfo6; text-align: justify; text-indent: -18.0pt;">4.<span style="font: 7pt "Times New Roman";"> </span>Sometimes it may be necessary to re-create a document (e.g., wrong work type) or to move a document, for example, if it was originally posted incorrectly or indexed to the incorrect patient record. </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;"><b style="mso-bidi-font-weight: normal;">C.<span style="font: 7pt "Times New Roman";"> </span></b><b style="mso-bidi-font-weight: normal;">WHEN A PERTINENT ENTRY WAS MISSED OR NOT WRITTEN IN A TIMELY MANNER, THE AUTHOR MUST MEET THE FOLLOWING REQUIREMENTS: </b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l2 level1 lfo5; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Identify the new entry as a “late entry” </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l2 level1 lfo5; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time. The entry must be signed. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l2 level1 lfo5; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>Identify or refer to the date and circumstance for which the late entry or addendum is written. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l2 level1 lfo5; text-align: justify; text-indent: -18.0pt;">4.<span style="font: 7pt "Times New Roman";"> </span>When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;"><b style="mso-bidi-font-weight: normal;">D.<span style="font: 7pt "Times New Roman";"> </span></b><b style="mso-bidi-font-weight: normal;">AN ADDENDUM IS ANOTHER TYPE OF LATE ENTRY THAT IS USED TO PROVIDE ADDITIONAL INFORMATION IN CONJUNCTION WITH A PREVIOUS ENTRY. </b></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l5 level1 lfo4; text-align: justify; text-indent: -17.45pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Document the date and time on which the addendum was made. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l5 level1 lfo4; text-align: justify; text-indent: -17.45pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Write “addendum” and state the reason for creating the addendum, referring back to the original entry. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l5 level1 lfo4; text-align: justify; text-indent: -17.45pt;">3.<span style="font: 7pt "Times New Roman";"> </span>When writing an addendum, complete it as soon as possible after the original note. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;"><b style="mso-bidi-font-weight: normal;">E.<span style="font: 7pt "Times New Roman";"> </span></b><b style="mso-bidi-font-weight: normal;">ERRORS IN SCANNING DOCUMENTS </b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">If a document is scanned with wrong encounter date or to the wrong patient, the following must be done: </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Reprint the scanned document. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Rescan the document to the correct date or patient, and void the incorrectly scanned document in the permanent document repository. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;"><b style="mso-bidi-font-weight: normal;">F.<span style="font: 7pt "Times New Roman";"> </span></b><b style="mso-bidi-font-weight: normal;">ELECTRONIC DOCUMENTATION – DIRECT ONLINE DATA ENTRY </b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">Note: The following are guidelines for making corrections to direct entry of clinical documentation, and mechanisms may vary from one system to another. </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>In general, correcting an error in an electronic/computerized medical record should follow the same basic principles as corrections to the paper record. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>The system must have the ability to track corrections or changes to any documentation once it has been entered or authenticated. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>When correcting or making a change to a signed entry, the original entry must be viewable, the current date and time entered, and the person making the change identified. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; text-align: justify;"><br />
</div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;"><b style="mso-bidi-font-weight: normal;">G.<span style="font: 7pt "Times New Roman";"> </span></b><b style="mso-bidi-font-weight: normal;">COPY AND PASTE GUIDELINES </b></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">The “copy and paste” functionality available for records maintained electronically eliminates duplication of effort and saves time, but must be used carefully to ensure accurate documentation and must be kept to a minimum. </div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l6 level1 lfo1; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>Copying from another clinician’s entry: If a clinician copies all or part of an entry made by another clinician, the clinician making the entry is responsible for assuring the accuracy of the copied information. </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l6 level1 lfo1; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>Copying test results/data: If a clinician copies and pastes test results into an encounter note, the clinical-provider is responsible for ensuring the copied data is relevant and accurate. </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l6 level1 lfo1; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>Copying for re-use of data: A clinician may copy and past entries made in a patient’s record during a previous encounter into a current record as long as care is taken to ensure that the information actually applies to the current visit, that applicable changes are made to variable data, and that any new information is recorded. <br />
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</div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com0tag:blogger.com,1999:blog-531358123458879241.post-79137433545219639182011-05-21T13:03:00.000-07:002011-05-24T13:19:53.564-07:00RETENTION AND DESTRUCTION OF MEDICAL RECORDS<div class="MsoNormal" style="line-height: 150%; text-align: justify;">All Medical Records are retained for at least as long as required by State and federal law and regulations, and UC__ policies and procedures (see: “Records Retention” and No. ____, “Records Storage and Destruction”). The electronic version of the record must be maintained per the legal retention requirements as specified in Policy No. _____ (UC Campus) “Record Retention” or consult with Campus Legal Counsel. </div><div class="MsoNormal" style="line-height: 150%; text-align: justify;">A. In the event that an original Medical Record cannot be located, a temporary medical record folder will be created as follows:<br />
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<a href="http://medical-record.blogspot.com/">http://medical-record.blogspot.com</a>/ <br />
</div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">1.<span style="font: 7pt "Times New Roman";"> </span>All identified original documentation held for filing in the original record will be included in the temporary folder; Legal Medical Record Standards Policy No. 9420 </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">2.<span style="font: 7pt "Times New Roman";"> </span>A notation will be made in the record by the Medical Records Department Supervisor or Manager that the record is a temporary chart being used until the original can be located; </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">3.<span style="font: 7pt "Times New Roman";"> </span>As needed, online documents will be printed and filed into the temporary folder; </div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">4.<span style="font: 7pt "Times New Roman";"> </span>The temporary folder will be tracked in the computerized chart tracking system by means of a special volume number to distinguish it from the original and to indicate that it is a temporary chart; </div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -18.0pt;">5.<span style="font: 7pt "Times New Roman";"> </span>Upon location of the original record, all material from both the original and temporary folder will be incorporated into the original folder, and the temporary folder will be removed from the computerized tracking system.<br />
<a href="http://medical-record.blogspot.com/%20">http://medical-record.blogspot.com/ </a><br />
</div>Rafless bencoolenhttp://www.blogger.com/profile/03049098776512473429noreply@blogger.com2