1. 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

2. 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.

3. The Medical Record
Chapter 9

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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”

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. Student Responsibilities
Unit 6
Post to the Discussion Board
Participate in Seminar or complete Option 2
Complete Unit 6 Quiz
Due EOD
Unit 7
Post to the Discussion Board (by
Complete Option 2 or Option 2 Lite
Due EOD
No Seminar for this Unit

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