DOCUMENTATION

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					Overview of
Documentation
KNR 279
DOCUMENTATION
   What is documentation?
    A  permanent legal record that is standardized
      and systematic
        Permanent
        Legal

        Standardized
Who Reads What You Write?
   Physicians               Internal Auditors
   Psychiatrists            Insurance Companies
   Nurses                   Medicare surveyors
   Allied Health            JCAHO surveyors
    Professionals            Attorneys
   Hospital Committees      Judges
   CQI                      Juries
   Administrators           And the list goes on
DOCUMENTATION
   Why do we document?
     Assure quality services
     Communicate with staff
     Professional accountability
     Provides information to be evaluated
     Provides information to determine efficacy
     Requirement
DOCUMENTATION
   Types of documentation
     Program  Documentation
     Client Documentation
PROGRAM DOCUMENTATION
 Written plan of operation
 Comprehensive program
 Protocols
 Quality improvement documents
 Program evaluation
 Policy & procedure manuals
 Staff manuals
CLIENT DOCUMENTATION
 Assessments
 Treatment plans
 Progress notes
 Discharge notes
 Referral summaries
 Participation records
 Other agency records
DOCUMENTATION
   Flow pattern for client documentation
     Assessment
     Assessment  summary
     Goals & objectives
     Treatment plan
     Progress notes
     Discharge notes
PURPOSE OF RECORD
DOCUMENTATION
 Benefit to patient, staff, physician
 Communication tool for planning patient
  care
 Utilization review
 Reimbursement
 Quality Assurance, research, program
  evaluation
 Legal document, accountability
DOCUMENTATION
   How would you define good
    documentation?
     Accurate
     Good  writing skills
     Black / blue ink
     Legible
     Honest, factual & timely
     Signed with credentials
     Confidential
What is Confidentiality?
 Right to share privileged information with
  healthcare provider
 Provider keeps the information confidential
     Pt’s identity, condition, emotional state,
      financial state
   Right to be free from unnecessary probes
    into personal affairs
                burlingame
CONFIDENTIALITY: THINGS
TO AVOID
 Discussing patient/work situations with
  family and friends
 Informal discussions with colleagues
 Inappropriate conversational remarks to
  consumers, visitors or employees
 Incoming phone call in nonconfidential
  settings
CONFIDENTIALITY
 Talking about work at parties, bar, etc.
 Speaking with client in front of other clients
 Identifying clients outside of the hospital
HIPAA
   Health Insurance Portability and Accountability
    Act of 1996
   Developed by U.S. Dept. of Health & Human
    Services (HHS)
   National standards to protect the privacy of
    personal health information
   1st ever federal privacy standards
   Took effect April 14,2003
HIPAA
 Enforced by HHS Office for Civil Rights
 Who?
     Any  healthcare professional authorized to
      enter information in medical records
     All employees, staff, students, & other clinical
      personnel
Patient Protections
   Access to medical records
     Can   inspect, get copies, request corrections
   Notice of privacy
     How   intend to use personal information
 Limits on use of personal medical info.
 Prohibition of marketing
Patient Protections
   Must have written privacy procedure
    including
     Staff
          that have access
     How information can be used

   Must have employee training and privacy
    officer
Individually Identifiable Health
Information
   Demographic data (name, address, birth date,
    phone number, etc.)
   Past, present, or future physical or mental health
    or condition
   Provision of health care to person
   Past, present, or future payment
   THAT identifies the person, or for which there is
    a reasonable basis to believe it can be used to
    identify the person
Individually Identifiable Health
Information
   All medical records including but not
    limited to doctors’ notes & orders, x-rays,
    lab reports, nurses’ notes, etc.
Use & Disclosure
 Treatment
 Payment
 CQI
 Research
 Education
 Law suits & other required disclosures
     (Public   health, abuse, worker’s comp.)
Civil & Criminal Penalties
   Monetary
     Up to $100 per violation
     Up to $25,000 per year
     For each requirement or prohibition violated
Civil & Criminal Penalties
   Criminal
     Up  to $50,000 & 1 year in prison
     Up to $250,00 & 10 years in prison
     IF offenses committed with intent to sell,
      transfer, or use protected health information
      for commercial advantage, personal gain, or
      malicious harm.

				
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posted:8/7/2011
language:English
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