The use cases described in the results section illustrate the benefits of the EPDS framework. Its usefulness is discussed below as a legal/compliance guideline as well as clinical value. In 2012, the Alliance for Clinical Education (ACE)8 issued a statement recommending that students have the opportunity to document in the EHR. CMAs have taken different approaches to address these educational needs. For example, some schools have created a mirror version of the EHR where students can practice documentation and decision-making. At our CMA, a multidisciplinary committee was convened in 2017 to discuss how to improve the student learning experience while maintaining quality of care. Key factors were the framework presented here and the recognition that the WASH is not equivalent to the MRL/SRD. A student`s grade may indeed exist in the FSD, but by definition may not be formally part of the DRS/RMT. This gave students full access to patient records, placed orders for review and approval with authorized providers, and created OPSI notes characterized by an automatic header “for training purposes only.” Student grades were categorized in a separate EHR tab. For many people, all the information contained in the electronic health record (EHR) is synonymous with “medical record” or even “legal medical record”. This is a false concept in today`s electronic world of bits and bytes. Rather, the EHR is a “data store” for each patient – a set of patient-specific data elements. Most are collected during care, but some come from data from other organizations – only some of which are relevant to current patient care.
Other elements are software system data and, although patient-specific, they are only used to ensure the proper functioning of the system. In the struggle at our CMA to more clearly understand the complexity of the EHR, the focus was first on data that “match” the definitions of the LMR and DRS. The official business record of health services provided by the Company for regulatory and disclosure purposes. HIPAA makes it clear that psychotherapy notes, as defined below, are not part of the MRL or DRS. Medical images and photographs ARE clinically relevant and used for medical decision making. The complication experienced by many institutions is the centralized storage and quality reproduction of images when publishing the legal medical record, especially on paper. If the images are kept in different systems and devices that HIM may not have immediate access to, it will be difficult to include and share them consistently in the LHR definition. When documents are published on paper, the quality of a reproduced image, especially with monochrome printers, is compromised and can be completely unreliable.
If the documentation refers to what can be seen in the medical images and interpreters, these reports would be part of the RSL and could meet the requirements of many release applications. And while these considerations may lead some institutions to exclude medical images from their definition of RSL, that doesn`t mean they`re not useful and can be released upon specific request. Some types of records belong to both the specified record and the statutory health record. Some belong only to the specified record. By categorizing record types, organizations can define policies for each recordset. When defining the specified record, the privacy policy does not specifically refer to source data such as pathology slides, diagnostic films, and traces. However, the narrative text throughout the preamble suggests that it would be generally acceptable to provide interpretations from the source data in the intended set of records. In most cases, individuals cannot interpret the source data, so the data is meaningless. On the other hand, interpretations of source data provide individuals with the information they need to make informed decisions about their health care.
However, the same criteria used by organizations to determine which paper records should be retained and included in their statutory health records and established records can be applied to electronic records. The questions organizations need to ask are: For years, healthcare organizations have struggled to define their legal health records and align them with the record required by the HIPAA privacy rule. Questions often arise about the differences between the two sentences, as both identify information that must be disclosed upon request. Debbie received her bachelor`s degree in medical records management from the University of Kansas, Lawrence Kansas. She also earned a Bachelor of Medical Science degree from Midland College in Fremont, Nebraska. Organizations should define the types of documentation that make up the defined dataset and indicate where records physically exist, such as in separate and multiple paper or electronic systems.† The increasing volume of health records increases the challenge of defining and assembling these sets of records. An individual`s record may include records from a facility, results of ambulatory diagnostic tests or therapies, pharmaceutical records, medical records, records of other health care providers, and the patient`s personal health record. Administrative and financial documents and data can be mixed with clinical data. Under HIPAA, the designated record is used to clarify the rights of individuals to access, amend, restrict, and acquire accounting for disclosures.
Individuals have the right to access and obtain a copy, request changes, and set restrictions and billing for medical and billing information used to make decisions about their treatment. The challenge for HIM professionals in defining the statutory health record or overall record is to determine which data elements, electronically structured documents, images, audio files, and video files to include. The primary consideration when defining the statutory health record and the named record should always be the need for immediate and long-term care for patients. A HIM committee, composed primarily of members of the patient care team, can lead this process. Members of this committee should decide which information is clinically significant.† 1. All patient care provided directly in the facility`s care facilities, including through an electronic portal and remote devices, must be adequately documented within certain policy timelines in the electronic health record, where applicable. Many states have laws or regulations that give individuals the right to their health information. Some state laws may define health information more broadly than the privacy rule. Some states may not restrict access to and modification of PHRs in a particular record.
If state laws or regulations grant individuals greater access rights, the entity concerned must comply with state law. The legal health record is generally used to respond to formal inquiries for evidentiary purposes. This does not affect the possibility of finding other information held by the organization. As technology evolves, other characteristics must be assessed and considered in legal health records and established records policies. Documents that are not yet complete or are in the intermediate/pending state should be considered. Functions such as clinical decision support triggers and annotations must also be considered.