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HIPAA & Documentation Issues

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Jessica Howkins

on 26 July 2016

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Transcript of HIPAA & Documentation Issues

Thank You!
New Hope Clinic
HIPAA & Documentation Issues

Respecting the right to privacy is a basic tenant of New Hope Clinic.
In addition to information about patients, no information regarding the following shall be released without written permission, except as required by law:
A volunteer
A Board Member
An Employee
Business plans, confidential reports, contracts, as well as other information specific to NHC
Privacy of Other Information
Patients must submit a HIPAA compliant request to have PHI records released to others or to obtain a copy for themselves.

Forms are available in the filing cabinet in reception

Signed requests are placed in the Admin Office for processing

Requests must be processed by someone who has been approved by the Privacy Officer
Release of PHI
Please read and sign “Confidentiality Agreement and Training Certification.”
Any Questions?
Review and follow appointment scheduling guidelines in scheduling program. Although it is hard to tell a patient they have a long wait time for their appointment date, it is not fair to the other patients who have already waited if the provider must rush their visit to squeeze someone extra in. Click the 'wait list' button on the scheduling box so we can contact them if their are cancellatoins.

We do not accept medication donations from individuals (according to NC Board of Pharmacy regulations). Suggest to donors that a nursing home may be able to use them if they are not expired and are unopened. Sheriff’s offices and the Boiling SpringLakes police department have drop off boxes for destruction.

Do not allow anyone to do work on the building unless authorized by Executive Director.

When receiving delivery of packages – be sure to check that the
number of packages
indicated on the delivery person’s form/handheld matches the number of packages you receive.
General Notes
for Smooth Operations
Indication of patient’s comprehension and intent to follow through
Pamphlets given
Classes scheduled
Return visits needed to office are noted even if it is PRN
Educational Efforts Regarding
Treatment Plans
All Charts:
Write Legibly
All entries dated & signed
Stamp below all providers’ names, without covering any writing
Write only with BLACK pen. Use RED for allergies
Legal Charting
ALL notations dated, legible and signed

Document all no-shows, re-scheduling and cancellations, including type of appointment. We need to try to reschedule and document these attempts in the chart.

Document diagnostic tests with date received, reviewed, and communicated to patient along with any treatment plan or follow up visits required.

Document medication changes

All orders (medications, tests) must be signed by prescriber/ordering provider. Documentation by nurses or medical assistants of verbal orders must be co-signed by prescriber/ordering provider.
Progress Note Page
Patient full name and date of birth printed on every page

Each section is kept in chronological order, with newest information on top

In red, all drug allergies reported by patient, updated at each visit

Medical History reviewed and signed by medical personnel at first visit, entered into Electronic Health Record Patient Problem List
Required Chart Components: Paper Charts
Make comments brief and concise, but written in a manner that someone else can understand exactly what happened
Facts only, not personal interpretations
No negative subjective comments about behavior
Only use approved abbreviations
Documentation Basics
Always verify you are accessing the correct chart by asking the patient to tell you their Date of Birth

All results, reports and records from other providers must be reviewed and initialed by a NHC Provider, then scanned & keyed into their electronic record before being filed in charts

After we complete the transition to Electronic Health Records, we will still maintain a paper chart for pharmacy pickup records, consent forms and eligibility documents

All clinical information for patients should now be entered in the EHR. Check training guides for directions on how to document interactions with patients or take notes on paper/phone messages until you can check with another staff member.
Chart Basics
Patients have the right:
To receive a paper copy of Notice of Privacy Practice
To lodge a complaint
To request restrictions on uses and disclosures
To request access to PHI for inspection or copying
To request an amendment to their records
To request an accounting of any disclosures
Patient Privacy Rights
Protecting Health Care
Computer access:
Each user must have a unique login and unique confidential password

Users must not release their login and/or password or allow anyone to access or alter information under their login

Users must lock or logoff the computer when their workstation is unattended. Software is configured to automatically lock after a period of inactivity. Be sure to logoff at the end of your shift.

Immediately report any suspected breaches of security or integrity of the system
When visitors and/or other patients are present make sure that health care information is not visible

Do not talk about a patient’s condition, disease, or personal information in public areas of the clinic even if you do not use a patient name

Under Federal regulations there is limited access to patient information on a need to know basis – You may not review PHI data that is not related to your job functions in the clinic.
Protecting Health Care Information
Any information received as a result of your work with New Hope Clinic.
Includes any personal information such as:
Patient presence at the clinic
Fact that they are a patient
Health status or type of health issue
Any personal information, including family issues
What is Protected
from Disclosure?
To protect health information that has not been authorized to be used or disclosed

To provide every person with privacy protection no matter what state you live in

To provide control to the patient on how their health information is used and disclosed
Purpose of the Privacy Rule
Doctors, nurses, pharmacists, clinic employees/volunteers and many other health care personnel

Government programs that provide for health care

Insurance companies
Who must follow the law ?
HIPAA Facts & Definitions
Be sure to Sign-In and Sign-Out every time you volunteer
To collect an accurate value of your volunteer time
To know who is in the building

Check for updates in the “Communications Notebook” located under the sign-in sheet at the beginning of each shift.

Wear your nametag

If you must cancel, please give us as much advance notice as possible. If you have friends or co­workers who also volunteer, please try and trade times, or find a replacement if possible.

Ask about the things you don’t understand.
General Notes
for Smooth Operations
Tracking of Files
Please use Red Tag folder to note location of files when out of cabinets

Inactive Files
Stored securely in storage room
Check NHC Patient Database for correct file cabinet location, based on year of last visit date

Security of files
Kept in a restricted area
Do not leave files unattended (Example: in Eligibility, Triage, Exit or Exam rooms)
Never leave in room with patient when you are not present
Chart Files
Correcting or Editing Records:
Strike through any original documentation you are removing with a single line
Leave all words legible
Initial and date change
Never back date a correction or entry
Do not obliterate the original words
Never use correction fluid on any part of the chart
Under no circumstances write the word error
Legal Charting
If someone calls the clinic and asks if a patient is there, politely state that you cannot give them any confidential information

If they are calling from a healthcare facility about treatment for the patient, transfer the call to a healthcare provider or the privacy officer

Otherwise, advise them to contact the patient directly, but do not release contact information

If they give you a difficult time or you have any questions, put them on hold and refer to the Executive Director or designee, but do not divulge the patient’s presence
How to Handle Questions about a Patient
To the individual

For treatment, payment and health care operations

When legally required by State, Federal and local authorities (Example, court order, death certificate, neglect and abuse)
Permitted Use and
Disclosure of Information
Information in the medical record

Conversations about the treatment or care with the health care team

Billing and payment information
What is protected?
Health care information is protected under Federal Law
"PHI" = Personal Health Information
"Authorization" = written permission by patient or legal representative
Shred all discarded documents containing PHI

Place all documents and charts face down or facing the wall in the presence of patients and visitors

Escort patients and visitors at all times

Close doors to exam rooms when patients are present

Interview patients in private when related to any PHI
Protecting Health Care Information
Health Insurance Portability Accountability Act of 1996
Phone Calls
When taking a call from or about a patient:
Write the message on a phone message book page (
a scrap of paper)
Write down the patient’s full name, date of birth, phone number and who is calling (if not the patient)
Write out a complete message that can be understood without contacting you or the patient
Sign the message
Give the message and the relevant patient chart to the appropriate person

When calling a patient:
Check the Consent Tab in the patient chart for the PHI Form to see how much of a message the patient has authorized us to leave on a machine or with another person
If the form is not clear, leave a basic message requesting that the individual returns your call at New Hope Clinic
(specific consent is required in certain situations, example referrals or requests for information from another provider)
Security standards for the protection of personal health information
Full transcript