HIPAA
Health Insurance Portability and Accountability Act
What is the primary purpose of a health record?
To exchange information among the healthcare professionals to determine problems strengths, plan and record appropriate treatment, and complete all legal documentation that is required.
The health record is a legal document. It includes:
-past and present medical information
-proof for advance directive
-course of treatment
-related correspondence
Health record Personal info:
-identifying information
-demographics
-contact info
-privacy notices
Health record Medical info:
-doctor info
-Insurance information
-medical diagnosis
-vitals
Types of records...
Electronic Health Record (EHR)
Electronic Medical Record (EMR)
Education records
Personal Health record
EHR (Electronic Health Record)/ EMR (Electronic Medical Record)
-Both contain and manage health information about a client.
-These are maintained by the provider.
-Many different types of software applications available.
-Incentives for electronic documentation for clinical quality measures.
-several different medical
FERPA
Federal Education Rights and Privacy Act
student's rights and privacy regarding his/her education records.
allows for student/parent to fully review student's education record.
Education Records
communication between personnel who work with a child.
special ed and related services documentation
PHR
Personal Health Record
-i.e. my chart. patient use at home.. log in and see past medical records/history.. but not a full view of all records.
1996
national standards to manage and protect the privacy and security of an individual's health information.
-specified regulations for the use and disclosure of PHI(protected health information)
HIPAA
Storage and maintenance of records...
-must stay on site
-must follow HIPAA
-kept in locked cabinet
-never left on desk, etc.
-angle computer away from others
-log out
Advocated the POMR (problem-oriented medical record) in 1960 to provide more structured and client-centered approach to the medical record. Called it the SOAP note.
Dr. Lawrence Weed
What are the four components of the problem-oriented medical record?
-patient's history & physical evaluation by all disciplines
-list of client's problems
-interdisciplinary treatment plan created by all
-progress notes (chronological order)
S
O
A
P
Subjective
Objective
Assessment
Plan
Subjective
-client stated
-client's perception of treatment, progress, limitations and problems
Objective
-health professional observations of treatment provided.
Assessment
-skilled judgement
-interpretation of the meaning from observations; including limitations and expectations of client's ability to benefit from therapy
Plan
-the future plans to continue with goals and objectives in the intervention plan
Source-oriented medical record
-used to organize the client's health information in a chart.
-records are divided into disciplines
-nursing
-lab results
-therapy
-ER
-contact notes
Users of health records:
-business development
-client care management
-reimbursement
-legal system
-evidence and research based practice
-accreditation
-education
-public health
-the client
-quality improvement
What to write?
What services, when and where
What happened and what was said
skilled OT needed, why?
How client responded to treatment.
the don'ts of writing a soap note
-make generalities
-leave out important information
-make judgments
-make errors with copying information
Writing Rules
FYI
use black ink
never use white out
correct errors
do not erase
do not leave blank spaces or lines
make sure all specific information is present
sign and date your notes
be concise
use of appropriate terminology
use of appropriate abbreviations
refer to you