HS101 Seminar Rubric Grade Evaluation Criteria Points A 90-100% B Frequent interactions on concepts being discussed by students and instructor Posts are on topic and contribute to the quality of the seminar Student arrives on time and stays the entire seminar Student supplies reference to back up comment 90-100% 18-20 points B Some interactions on concepts being discussed by students and instructor Posts are generally on topic and contribute to the quality of the seminar Student is tardy or leaves early 80-89% 16-17 points C Few interactions on concepts being discussed by students and instructor Student is tardy and leaves early 70-79% 14-15 points D No interactions on concepts being discussed by students and instructor Off topic conversations Student attends less than half of the seminar Student appears unfamiliar with seminar topic 60-69% 12-13 points F Off topic conversations and/or abusive or inappropriate behavior No interactions with students and instructor Student attends a fraction of the seminar <60% 0-11 points HS101 Seminar Rubric

Unit 6 Objectives HS101-U5-1: Describe the purpose of the medical record. HS101-U5-2: Discuss the use of electronic medical records. HS101-U5-3: Discuss federal and state health care regulations covering medical records. HS101-U5-4: Describe measures taken by health care professionals to maintain the integrity of medical records. HS101-U5-5: Explain how legal regulations and ethical standards may come into conflict. HS101-U5-6: Explore state laws regarding the mandatory reporting of infectious diseases and suspected abuse. HS101-U5-7: Identify governmental reporting agencies responsible for mandatory reporting.

The Medical Record Chapter 9

The Medical Record All written documentation relating to patient Includes Past history Current diagnosis and treatment Correspondence relating to patient Is a legal document May be subpoenaed

Purpose of the Medical Record Record of patient from birth to death Document for continual management of patient’s health care Provides data and statistics Tracks ongoing patterns of patient’s health

Contents of the Medical Record Personal information about patient Clinical data or information Records of medical examinations X-rays Lab reports Consent forms

Two Common Forms of Charting POMR: Problem-Oriented Medical Record includes chronological record of each visit SOAP: subjective, objective, assessment, plan Subjective statements of patient Objective data such as lab reports, vital signs Assessment or diagnosis Plan of treatment

Corrections and Alterations Draw one line through error Write correction above error Date and initial change Do not erase or use correction fluid Falsification of medical record is grounds for criminal indictment

Timeliness of Documentation Medical records must be accurate and timely All entries must be made as care occurs or as soon as possible afterward Should be completed within 30 days following patient's discharge from hospital

Completeness of Entries Medical records document type and amount of patient care that was given In eyes of court, “if it’s not documented, it wasn’t done”

Confidentiality Medical records should not be released to third parties without patient’s written consent Only specific records requested should be copied and sent Taking photos or other visual images of patient without consent is invasion of patient’s privacy

Ownership Physicians or owners of health care facility own medical record Patient’s have legal right of “privileged communication” and access to records Patients must authorize release of records in writing Doctrine of professional discretion: physician may determine, based on his or her best judgment, if patient with mental or emotional problems should view medical record

Release of Information Record may not be released to patient without physician’s permission Patient must sign release form for information to be sent to insurance company Never send entire medical chart unless it is requested

Privacy Act of 1974 Agency may maintain only information relevant to its authorized purpose Citizens have right to gain access to records and to copy records if necessary Applies only to federal agencies and government contractors

State Open Record Laws Some states have freedom of information laws that grant public access to records maintained by state agencies Medical records generally are exempt from this statute

Alcohol and Drug Abuse Patient Records Public Health Services Act protects patients who are receiving treatment for drug and alcohol abuse Person or program that releases confidential information relating to these patients is subject to criminal fines Exception if patient should require emergency care

Retention and Storage of Medical Records Each state varies on length of time records must be kept Legally, records must be stored for a minimum of seven years from time of last entry Minor’s records must be kept until patient reaches age of maturity plus period of the statute of limitations

Storage Current records usually kept within physician's office May rent storage space May be placed on microfilm

Computerized Medical Records Data on patient records can be created, modified, authenticated, stored, and retrieved by computer Special safety measures should be taken to establish personal identification and user verification codes for access to records Should be accessed on need-to-know basis

Reporting and Disclosure Requirements State laws require disclosure of some confidential medical record information without patient’s consent Reporting and disclosure are duties of the physician

Duty to Report AIDS, HIV, and ARC Cases All states require reporting of AIDS to local or state department of health Most states require HIV and ARC cases be reported as well Who reports cases varies by state Many states have confidentiality statutes that allow notification of an HIV patient’s spouse, needle-sharing partner, or other contact person who is at risk of the infection

Use of Medical Record in Court Improper Disclosure: health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization Subpoena Duces Tecum: written order requiring person to appear in court, give testimony, and bring information described in subpoena

Student Responsibilities Unit 6 Post to the Discussion Board Participate in Seminar or complete Option 2 Complete Unit 6 Quiz Due 12-20-11@ EOD Unit 7 Post to the Discussion Board (by 12-31-11 Complete Option 2 or Option 2 Lite Due 1-3-11 @ EOD No Seminar for this Unit

Happy Holidays Wishing you and all of your families a safe and happy holiday season and a great 2012!