1 LEGAL HEALTH RECORD: Definition and Standards DEVELOPING YOUR STRATEGY & Tool Kit Diane Premeau, MBA, MCIS, RHIA, RHIT, CHP, A.C.E.
2 OBJECTIVES Define Legal Health Record Differentiate between Designated Record Set and Legal Health Record Identify Components of Legal Health Record Policy Understand importance to E-Discovery
3 What is a Legal Health Record? Information created, received or maintained by an organization that is the business record of activities, operations Record has value requiring adherence to regulatory and retention rules. Generated for healthcare and would be released upon request.
4 Where is the Legal Health Record? E.HR Systems E.HR Content Designated Record Set LEGAL HEALTH RECORD
5 Definitions: Business Record A recording/record made or received in conjunction with a business purpose and preserved as evidence or because the information has value. Information is created, received and maintained about a person. Must be maintained to comply with applicable regulations, accreditation standards, professional practice standards & legal standards.
6 Legal Health Record (LHR) Record generated at or for a healthcare organization as its business record and is the record that would be released upon request. Supports decisions made in patient care. Supports claims for revenue. Serves as legal testimony regarding illness, injury, response to treatment, and caregiver decisions. Each entity MUST define the content & standards
7 Designated Record Set (DRS) (HIPAA ) A group of records maintained by or for a covered entity that is the: medical and billing records about individuals; enrollment, payments, claims records, medical management record systems maintained by or for a health plan (case management); information used in whole or in part by entity to make decisions about individuals.
8 Hybrid Record Information that is maintained in a variety of media, including paper and electronic. Comprised of both paper and electronic processes to collect, store, retrieve and utilize the information. Hybrid record is more difficult to define and manage as legal record.
9 Electronic Health Record (E.HR) Medical information compiled in a data gathering format (point of care) for retention and transfer of Protected Health Information (PHI) via secured, and/or encrypted communication options. Can generate a health record of a clinical encounter May provide clinical decision support, alerts, outcomes reporting, quality monitoring. Components that can be released can be variable.
10 Personal Health Record (PHR) An Individuals own record, maintained by the individual, created by the individual and health care providers. PHR is separate from and does not replace the legal health record. Can be incorporated into Legal Health Record. Individual owns and determines access rights.
11 WHO IS THE CUSTODIAN Past: Director of HIM Present: Hybrid, E.HR - Several custodians Direct Custodian (typically HIM) Data Owner or Steward Business Associate/ Third Parties Office Record and Systems Custodian And.
12 Where is your Legal Health Record Define the location of your record from creation to storage Past: Chart order Present: Variety of Sources Best Practice - Development a matrix (attachment) Track source system, location, retention, media, designated record set Identify content external to organization
13 Where do you Start?? Do you know how your record is created? FIND ALL Systems All media Conduct a source system review Where, Who, What output? Do you have SPECIAL considerations? Mental Health, Custody, Children or??
14 Hybrid Record Matrix IP Document (list all your documents) VIEWING LOCATION Source System SCANN ED Locatio n for Legal Record (P, E) Part of Design ated Record Set Created by Interface 1 1. ADMITTING INFO Inpatient Admission Registration sheet Conditions of Admission Code Status Orders Medication Consents Legal Status documents: Organ Donation Form 2 ADMINISTRATIVE DOCUMENTS Advance Directive Alert Form Advance Directives Acknowledgement Interfacility transfer sheet Health Facility Minor Release Report Paper/ EDM Core System E Y Admitting System A Discharge Summary Paper/ EDM Chart Script No E Y Transcripti on System A Physician/Treatment Coordinator Discharge Summary Death Notice Death Certificate Worksheet Autopsy
15 Hybrid Matrix (con t) IP Document (list all your documents) Able to Print Version Management Back -up Location where stored Meta data Audit Trail Location of Training for Access Special Category (mental health, administrativ e 1. ADMITTING INFO Inpatient Admission Registration sheet Yes Yes Yes IT Yes Yes Admitting administrative Conditions of Admission Code Status Orders Medication Consents Legal Status documents: Organ Donation Form
16 Designated or Legal Health Record? STEP 1: Identify Record Content Understand DRS from LRS Designated Record Set Includes LHR PLUS medical and billing records; enrollment, payment, claims, health plan, decision making documents Legal Health Record Individually identifiable data in any medium collected and used in documenting healthcare services or health status. Excludes administrative, derived or aggregate data
17 STEP 2: Components of the Legal Health Record Policy? Identify content of the LHR Health records Business & legal record Administrative Clinical External Bills, H&P; Orders; Progress External patient care Encounter forms Notes; records Case Management Records Lab Reports/Diagnostics PHR Remittance advice Nursing Documentation Therapies (Designated Record Set Only) Authorizations/Consents Clinical Reports
18 Step3: Develop YOUR Standards LHR policy is NOT just a list of documents LHR policy defines how to manage the record. Part I: Define your Legal Record How created Who can create the record Formats Purpose Contents: Internal and External document
19 LHR Definition (Sample Legal Record Definition and Standards) The Legal Medical Record (LMR) is the documentation of services provided to an individual during any aspect of healthcare delivery and is patient-centric. The legal health record contains individually identifiable data, stored on any medium, collected and directly used in documenting healthcare or health status. The legal health record is the business record and is the record that will be disclosed upon request.
20 LHR: How Created & Format (Sample Legal Record Definition and Standards) The Legal Medical Record may be a hybrid record utilizing both paper-based and electronic documents, which are captured manually and via electronic processes. Only individuals authorized to do so by Hospital and/or Medical Staff Policies and Procedures make entries into the Legal Health Record.
21 LHR: Purpose (Sample Legal Record Definition and Standards) PURPOSE The Legal Health Record definition and standards set forth in this Policy provide a framework for the integrity of paper and electronic clinical documentation systems that compile and maintain Legal Health Records to meet patient care and regulatory requirements. The Legal Health Record contains sufficient information to identify the patient, support the diagnosis, justify the treatment and services, document the course and results of care, and promote the continuity of care among health providers. (CMS Language)
22 LHR: Source Data; External documents The Legal Health Record may include source data in the absence of documentation or interpretations. (e.g.. Fetal monitor strips, etc) The Legal Health Record may include records from other health care providers as the result of tests and exams when necessary for the evaluation of the patient and subsequent treatment.
23 PART II: Standards for LHR: Identify Standards for Managing your LHR Maintenance: How generated & maintained Confidentiality: Data access, Data release Content: Matrix plus rules of creation Drafts; System requirements for identification Authentication & Completion Security and Retention: Downtime, Back-up, Disaster Recovery
24 Maintenance: How generated & maintained Maintenance of the Legal Health Record Your LHR may be considered a hybrid record, consisting of both electronic and paper documentation. Documentation that comprises the LHR may physically exist in separate and multiple locations in both paper-based and electronic formats. (See Grid to identify type and location of documents). The Legal Health Record contents can be maintained in either paper (hardcopy) or electronic formats, including digital images, and can include patient identifiable source information, such as photographs, films, digital images, electronic messages (e.g. s) and fetal monitor strips. The electronic components of the Legal Health Record consist of patient information from multiple electronic health record source systems.
25 Confidentiality Personnel who access the electronic Health Record are required to have a unique user ID/ password, access to information is limited according to the minimum necessary rule and managed by role, as approved by designated management personnel.
26 LHR CONTENT Legal Health Record content shall meet all State and Federal legal, regulatory and accreditation requirements All documentation and entries in the record, both paper and electronic, must be identified with a minimum of two identifiers, preferably the patient s full name and a unique number. All record entries should be made as soon as possible after the care is provided, after an event occurs, or after an observation is made. An entry for the actual patient treatment or procedure will never be made in the Medical Record in advance of the service provided to the patient. Only forms/reports approved can be used to document or capture data in the Legal Health Record.
27 CONTENT Preliminary reports/documents are available for patient care until they are authenticated. Once a document/report has been authenticated by the author (Final version) only that version is electronically displayed or filed in the paper chart. Only approved abbreviations will be used in the Legal Health Record.
28 Completion All inpatient records must be completed within 14 days from the date of discharge. All ambulatory records will be completed immediately following the encounter. All operative and procedure reports will be completed immediately after surgery. All record entries are to be dated, the time entered, and signed. Certain electronic methods of authenticating the record, including methods such as passwords, access codes, or key cards may be allowed provided certain requirements are met. The methodology for authenticating the document electronically must comply with electronic signature policy. Do you have an electronic signature policy?
29 Define Standards for LHR (Advanced) Downtime (what are the options???) Corrections & Amendments: Paper; Scanned Documents Transcription Point of Care Systems Copy and Paste Guidelines: YES OR NO??
30 Maintenance All Health Records, regardless of form or format, must be maintained in their entirety, and no document or entry may be deleted from the record, except in accordance with the destruction policy.
31 Corrections and Amendments If records requiring correction are from an outside provider, the patient should be instructed to contact the originator for an amendment. The correction must indicate the reason for the correction, and the correction entry must be dated and signed by the person making the revision.
32 Correcting Electronic Version: Do you know the options?? Documents that are created electronically must be corrected by one of the following mechanisms: 1. Adding an addendum to the electronic document to indicate the corrected information, the identity of the individual who created the addendum, the date created, and the electronic signature of the individual making the addendum. 2. Preliminary versions of transcribed documents may be edited by the author prior to signing. A transcription analyst may also make changes when a non-clinical error is discovered prior to signing (i.e., wrong work type, wrong date, wrong attending assigned). 3. Once a transcribed document is final, it can only be corrected in the form of an addendum affixed to the final copy as indicated above. Examples of documentation errors that are corrected by addendum include: wrong date, wrong location, duplicate documents, or incomplete documents. The amended version must be reviewed and signed by the provider.
33 Corrections - Scanning Errors in Scanning Documents (if applicable) What are your options????
34 Corrections: Point of Care Electronic Documentation Direct Online Data Entry Note: The following are guidelines for making corrections to direct entry of clinical documentation, and mechanisms may vary from one system to another. 1. In general, correcting an error in an electronic/ computerized health record should follow the same basic principles as corrections to the paper record. 2. The system must have the ability to track corrections or changes to any documentation once it has been entered or authenticated. 3. When correcting or making a change to a signed entry, the original entry must be viewable, the current date and time must be entered, and the person making the change must be identified.
35 COPY & PASTE Organization specific. G. Copy and Paste Guidelines The copy and paste functionality available for electronic Medical Records eliminates duplication of effort and saves time, but it must be used carefully to ensure accurate documentation and must be kept to a minimum. Copying test results/data: If a clinician copies and pastes test results into an encounter note, the clinical-provider is responsible for ensuring the copied data is relevant and accurate.
36 E-Signatures Electronic signatures must meet standards for: Data integrity to protect data from accidental or unauthorized change (for example locking of the entry so that once signed no further untracked changes can be made to the entry); Authentication to validate the correctness of the information and confirm the identity of the signer (for example requiring signer to authenticate with password or other mechanism); Non-repudiation to prevent the signer from questioning that they signed the document (for example, public/private key architecture). At a minimum, the electronic signature must include the full name and either the credentials of the author or a unique identifier, and the date and time signed.
37 What is NOT the LHR? Secondary Patient Information Source data used to create summaries Administrative Data Derived Data Drafts, Work in Progress Audit Trails
38 Not Part of LHR Patient-identifiable source data A. Patient-identifiable source Examples include, but not limited to 1. Photographs for identification purposes 2. Audio recordings of dictation notes or patient phone calls. 3. Video recordings of an office visit, if taken for other than patient care purposes 4. Video recordings/pictures of a procedure, if taken for other than patient care purposes 5. Video recordings of a telemedicine consultation 6. Communication tools 7. Protocols/clinical pathways, best practice alerts, other knowledge sources. 8. A patient s personal health record provided by the patient to his or her care provider. 9. Medication reconciliation from an outside source (pharmacy, other providers) 10. Alerts, reminders, pop-ups and similar tools used as aids in the clinical decision making process.
39 Not Part of LHR Administrative Data Administrative data are patient identifiable data used for administrative, regulatory, and healthcare operations and for financial purposes. Examples include, but are not limited to: 1. Authorization forms for release of information 2. Correspondence concerning requests for records. 3. Birth and death certificates. 4. Event history/audit trails. 5. Patient-identifiable abstracts in coding system. 6. Patient identifiable data reviewed for quality assurance or utilization management. 7. Administrative reports.
40 Not Part of LHR Derived Data Derived data consist of de-identified information aggregated or summarized from patient records for statistical reporting, licensing and accreditation. Examples include, but are not limited to: 1. Accreditation reports 2. Best practice guidelines created from aggregate patient data. 3. External required reporting, public health records and statistical reports.
41 Not Part of LHR Draft Documents Draft Documents / Work in Progress. Electronic processes and workflow management require methods to manage work in progress. Draft/Interrupted documents are not considered a part of the official Medical Record until they are finalized and signed by an authorized signer.
42 Not Part of LHR Audit Trails An audit trail is part of the metadata created around a document. It is composed of all transactions and activities, including access, associated with the health record. Elements of an audit trail may include date, time, nature of transaction or activity, and the individual or automated system linked to the transaction or activity.
43 Legal Health Record & E-Discovery Other considerations for E.HR s Clinical Decision Support Functions Prompts Alerts System Notifications
44 Next Steps.. Evaluate E-Discovery Process against systems and record management. Understand how systems handle deleted, shadow, versions, temporary documents, data. Identify Who can provide system information, reports?
45 Resources/Reference List AHIMA. "Fundamentals of the Legal Health Record and Designated Record Set." Journal of AHIMA 82, no.2 (February 2011): expanded online version. Dougherty, Michelle, and Lydia Washington. "Defining and Disclosing the Designated Record Set and the Legal Health Record." Journal of AHIMA 79, no. 4 (Apr. 2008): Available online in the AHIMA Body of Knowledge at Servais, Cheryl E. The Legal Health Record. Chicago, IL: AHIMA, Deleting Errors in the EHR (AHIMA September 2010, Working Smart) AHIMA e-discovery Task Force. "Litigation Response Planning and Policies for E-Discovery." Journal of AHIMA 79, no.2 (February 2008): Legal Electronic Health Record Policy Template. Body Of Knowledge
E-Discovery: A Deposition for your Electronic Health Record Sponsored by 1915 N. Fine Ave #104 Fresno CA 93720-1565 Phone: (559) 251-5038 Fax: (559) 251-5836 www.californiahia.org Program Handouts Wednesday,
E-Discovery: A Deposition for your Electronic Health Record Sponsored by 1915 N. Fine Ave #104 Fresno CA 93720-1565 Phone: (559) 251-5038 Fax: (559) 251-5836 www.californiahia.org Supplemental Handouts
North Shore LIJ Health System, Inc. Facility Name POLICY TITLE: The Medical Record POLICY #: 200.10 Approval Date: 2/14/13 Effective Date: Prepared by: Elizabeth Lotito, HIM Project Manager ADMINISTRATIVE
I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.17 Page: 1 of 6 This Policy applies to (1) Tenet Healthcare Corporation and its wholly owned subsidiaries and affiliates (each, an Affiliate ); (2)
Policy Level: Policy Title: Harborview Medical, rthwest Hospital & Medical,, UW Medical including Seattle Cancer Care Alliance, UW Neighborhood Clinics, Airlift rthwest and Hall Health UW Medicine Definition,
Guidelines for Defining the Legal Health Record for Disclosure Purposes Historically, the definition of the legal health record was fairly straightforward: the contents of the paper chart (together with
ELECTRONIC HEALTH RECORDS Medical Protective Clinical Risk Management Department AUGUST 2013 For questions, products, or services, please contact 800 4MEDPRO or visit http://www.medpro.com/. This document
Legal EHR Policy Template Developed by Members of the EHR Practice Council May 2007 How to Use This Tool Health care providers must maintain a health record that documents care and services provided to
I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.03 Page: 1 of 10 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)
ENTERPRISE POSITION STATEMENT TITLE: SHARED EMR LEGAL HEALTH RECORD GUIDANCE Original Effective Date: August 1, 2006 Effective Date of Current Revision: April 1, 2012 Review/Revision Date(s): April, 2012
Health Information Technology & Management Chapter 4 ORGANIZATION, STORAGE, AND MANAGEMENT OF HEALTH RECORDS BY : NOHA ALAGGAD PAPER CHARTS Consist of one or more file folders containing handwritten notes,
Record Custodian to Health Information Steward Best Practices in Record Retention, Storage, and Destruction Indian Health Services Health Information Management Meeting Sharon Lewis, MBA, RHIA, CHPS, CPHQ
Health Information Technology and Management 6 CHAPTER Organization, Storage, and Management of Health Records Pretest (True/False) Professional responsibilities often require an individual to move beyond
Health Information Technology and Management CHAPTER 5 Healthcare Records Pretest (True/False) The primary source of a patient s medical history is the patient or a relative. Consent to treatment and informed
Policies of the University of North Texas Health Science Center Chapter 14 14.601 Electronic Health Record Policy UNT Health Policy Statement. The University of North Texas Health Science Center (UNTHSC)
Final National Health Care Billing Audit Guidelines as amended by The American Association of Medical Audit Specialists (AAMAS) May 1, 2009 Preface Billing audits serve as a check and balance to help ensure
HL7 EHR-S Records Management & Evidentiary Support Functional Profile Michelle Dougherty, RHIA, CHP HIT Standards AHIMA for the Legal EHR email@example.com An educational update to the HIMSS
Cloning and Other Compliance Risks in Electronic Medical Records Lori Laubach, Partner, Moss Adams LLP Catherine Wakefield, Vice President, Corporate Compliance and Internal Audit, MultiCare 1 AGENDA Basic
Health Information Technology & Management Chapter 2 HEALTH INFORMATION SYSTEMS INFORMATION SYSTEM *Use of computer hardware and software to process data into information. *Healthcare information system
HIPAA NOTICE OF PRIVACY PRACTICES Marden Rehabilitation Associates, Inc. Marden Rehabilitation Associates of Ohio, Inc. Marden Rehabilitation Associates of West Virginia Health Care Plus Preferred Care
HIMSS Electronic Health Record Definitional Model Version 1.0 Prepared by HIMSS Electronic Health Record Committee Thomas Handler, MD. Research Director, Gartner Rick Holtmeier, President, Berdy Systems
Electronic Signature, Attestation, and Authorship Appendix C: Electronic Signature Model Policy This template document is not intended for adoption as a substitute for a customized organizational policy
Patient Privacy and HIPAA/HITECH What is HIPAA? Health Insurance Portability and Accountability Act of 1996 Implemented in 2003 Title II Administrative Simplification It s a federal law HIPAA is mandatory,
HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice
Electronic Medical Record Overview Saturday, January 31, 2015 POMA District VIII Winter Seminar Farmington, PA Presented by: Paula Snyder, RN, CPHRM Regional Manager, Risk Management DISCLAIMER The information
Special Topics in Vendor- Specific Systems Unit 4 EHR Functionality EHR functionality Results Review Outline Computerized Provider Order Entry (CPOE) Documentation Billing Messaging 2 Results Review Laboratory
TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE SECTION 300.1810 RESIDENT RECORD REQUIREMENTS
Issues in Electronic Health Records Management Electronic health records management (EHRM) is the process by which electronic (e.g., digital) health records are created or received and preserved for legal
Presented By: The National Learning Consortium (NLC) Developed By: Health Information Technology Research Center (HITRC) Vendor Selection and Management Community of Practice Version: 1.0 Date: October
Amendments, Corrections, and Deletions in Transcribed Reports Toolkit American Health Information Management Association 2009 Amendment Toolkit 2009 AHIMA 1 Table of Contents Foreword 3 Authors...3 Introduction
Alliance for Clinical Education (ACE) Student HIPAA Training Health Insurance Portability and Accountability Act of 1996 October 2003 1 Objectives Understand the HIPAA Privacy rules and regulations Understand
Health Information Technology and Management CHAPTER 2 Health Information Professionals Pretest (True/False) The American Health Information Management Association was originally called the Association
EHR Adoption and Vision for HIM Christina M. Janus, MBA, RHIA EOHIMA Spring Seminar April 14, 2007 1 Content Covered Key EHR Functions Adoption Model Group Share of Current Technologies & Vision for the
HIPAA and EMRs Issues to Consider Before Implementing an EMR Alexander Eremia, J.D., LL.M. Associate General Counsel and Corporate Privacy Officer MedStar Health, Inc. HCCA Compliance Institute Chicago,
HIT 2250 Seminar in Health Information Technology 3 Semester Credit Hours Course Information Course Description: A capstone course of research and testing based on all domains and knowledge clusters of
Health Information Management CTAG and Alignment This document contains information about three proposed Career-Technical Articulation Numbers (CTANs) for the proposed Health Information Management Services
HEAL NY Phase 5 Health IT RGA Section 7.1: HEAL NY Phase 5 Health IT Candidate Use Cases Interoperable EHR Use Case for Medicaid Interoperable Electronic Health Records (EHRs) Use Case for Medicaid (Medication
Rackspace Archiving Compliance Overview Freedom Information Act Sunshine Laws The federal government and nearly all state governments have established Open Records laws. The purpose of these laws is to
Network Detective 2015 RapidFire Tools, Inc. All rights reserved V20150201 Contents Purpose of this Guide... 3 About Network Detective... 3 Overview... 4 Creating a Site... 5 Starting a HIPAA Assessment...
2011 AHIMA Curriculum Competencies and Knowledge Clusters Health Information Management Associate Degree Approved by AHIMA Education Strategy Committee HIM Associate Degree Entry-Level Competencies (Student
Care360 EHR Frequently Asked Questions Table of Contents Care360 EHR... 4 What is Care360 EHR?... 4 What are the current capabilities of Care 360 EHR?... 4 Is Care 360 EHR an EMR?... 5 Can I have Care360
AHIMA Curriculum Map Health Information Management Associate Degree Approved by AHIMA Education Strategy Committee February 2011 HIM Associate Degree Entry-Level Competencies (Student Learning Outcomes)
Defining the Core Clinical Documentation Set for Coding Compliance Quality Healthcare Through Quality Information It is time to examine coding compliance policy and test it against the upcoming challenges
HIPAA Privacy Keys to Success Updated January 2010 HIPAA Job Specific Education 1 HIPAA and Its Purpose What is HIPAA? Health Insurance Portability and Accountability Act of 1996 Title II Administrative
HIPAA: In Plain English Material derived from a presentation by Kris K. Hughes, Esq. Posted with permission from the author. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub.
CHAPTER 14 INFORMATION TECHNOLOGY CONTROLS SCOPE This chapter addresses requirements common to all financial accounting systems and is not limited to the statewide financial accounting system, ENCOMPASS,
HEALTH INFORMATION MANAGEMENT SERVICES CONTACTS: Rita Bowen, MA, RHIA, CHPS, Enterprise Director of HIM Services Alicia Blevins, RHIA, CHP, HIM Record Completion/HPF Manager Pat McDougal, RHIT, HIM Coding
EMR Challenges Related to Billing and Revenue Cycle Lori Laubach, Principal Health Care Consulting California Primary Care Association Billing Managers Peer Conference May 20 21, 2014 1 The material appearing
HIM Associate Degree Entry Level Competencies (Student Learning Outcomes) I. Domain: Health Data Management A. Subdomain: Health Data Structure, Content and Standards 1. Collect and maintain health data
4658.00 (GENERAL) MINNESOTA Downloaded January 2011 4658.0015 COMPLIANCE WITH REGULATIONS AND STANDARDS. A nursing home must operate and provide services in compliance with all applicable federal, state,
RECORD RETENTION AND DESTRUCTION POLICY Scott A. Goffstein & Associates, LLP Scott A. Goffstein & Associates, LLP, recognizes that the firm s engagement and administrative files are critical assets. As
Retention & Disposition of Records Residing in a Public Cloud: A Risk Management Approach Patricia C. Franks, PhD, IGP, CA, CRM International Symposium October 17, 2014 to mitigate risk Not all information
Enterprise Content Management for Healthcare Achieve Operational Efficiency and Responsiveness Long deployment schedules and a lack of systems interoperability present two key challenges to the successful
Full Compliance for and EU Annex 11 With the regulation support of Contents 1. Introduction 2 2. The regulations 2 3. FDA 3 Subpart B Electronic records 3 Subpart C Electronic Signatures 9 4. EU GMP Annex
HIPAA Privacy and Security Course ID: 1020 - Credit Hours: 2 Author(s) Kevin Arnold, RN, BSN Accreditation KLA Education Services LLC is accredited by the State of California Board of Registered Nursing,
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) TERMS AND CONDITIONS FOR BUSINESS ASSOCIATES I. Overview / Definitions The Health Insurance Portability and Accountability Act is a federal law
HIPAA BUSINESS ASSOCIATE AGREEMENT This HIPAA Business Associate Agreement ("BA AGREEMENT") supplements and is made a part of any and all agreements entered into by and between The Regents of the University
GEORGIA MEDICAID TELEMEDICINE HANDBOOK CONNECTING GEORGIA OVERVIEW The Department of Community Health s (DCH) Telemedicine and Telehealth policies are slated to improve and increase access and efficiency
Health Insurance Portability & Accountability Act (HIPAA) Compliance Application IRB Office 101 - Altru Psychiatry Center 860 S. Columbia Rd, Grand Forks, North Dakota 58201 Phone: (701) 780-6161 PROJECT
United Cerebral Palsy of Greater Chicago Records and Information Management Policy and Procedures Manual, December 12, 2008 I. Introduction United Cerebral Palsy of Greater Chicago ( UCP ) recognizes that
HIPAA-G04 Limited Data Set and Data Use Agreement Guidance GUIDANCE CONTENTS Scope Reason for the Guidance Guidance Statement Definitions ADDITIONAL DETAILS Additional Contacts Web Address Forms Related
Introduction to Information and Computer Science: Information Systems Lecture 1 Audio Transcript Slide 1 Welcome to Introduction to Information and Computer Science: Information Systems. The component,
Chicago Homeless Management Information System (HMIS) Privacy Packet Table of Contents Standard Agency Privacy Practices Notice... 3 Chicago Standard HMIS Privacy Posting... 6 Client Consent Form for Data
I II Compliance Compliance I Compliance II SECTION ONE COVERED ENTITY RESPONSIBILITIES AREA ONE Notice of Privacy Practices 1 Is your full notice of privacy practices given to every new patient in your
7Seven Things You Need to Know About Long-Term Document Storage and Compliance Who Is Westbrook? Westbrook Technologies, based in Branford on the Connecticut coastline, is an innovative software company
DOCUMENTATION WAKE-UP CALL: HOW TO PREVENT DOCUMENTATION DEFICIENCIES AUTHORS: MARY C. MALONE, ESQUIRE MARY P. CHILES, RN, RAC-CT I. INTRODUCTION Concise clinical record documentation is critical to providing
HIPAA COMPLIANCE What is HIPAA? The Health Insurance Portability and Accountability Act (HIPAA) also known as the Privacy Rule specifies the conditions under which protected health information may be used
Union County Electronic Records and Document Imaging Policy Adopted by the Union County Board of Commissioners December 2, 2013 1 Table of Contents 1. Purpose... 3 2. Responsible Parties... 3 3. Availability
State of the EHR: The Vendor Perspective AHIMA is the national association of health information management (HIM) professionals. AHIMA s 50,000 members are dedicated to the effective management of personal
SBA Procedural Notice TO: All SBA Employees CONTROL NO.: 5000-1323 SUBJECT: Acceptance of Electronic Signatures in the 7(a) and 504 Loan Program EFFECTIVE: 10/21/14 The purpose of this Notice is to inform
WACHA Going Paperless Presented by: PAUL A. CARRUBBA Adams and Reese LLP Phone: (601) 292-0788 E-Mail: firstname.lastname@example.org Paul Carrubba Paul.Carrubba@arlaw.com Paul is a partner in the law firm of
Electronic Health Record Course Health Science Unit II Communication Essential Question What is an electronic health record? TEKS 130.204 (c) 4A, 4B, 5A, 5B Prior Student Learning Basic understanding of
Record Keeping College publications contain practice parameters and standards which should be considered be all Ontario physiotherapists in the care of their patients and in the practice of the profession.
Office of the Chief Information Officer Online File Storage BACKGROUND Online file storage services offer powerful and convenient methods to share files among collaborators, various computers, and mobile
2011 AHIMA Curriculum and Knowledge Clusters Health Information Management Baccalaureate Degree Approved by AHIMA Education Strategy Committee HIM Baccalaureate Degree Entry-Level I. Domain: Health Data
Accelerating HIPAA Compliance with EMC Healthcare Solutions A HealthCIO White Paper Sponsored by the EMC Corporation by Jonathan Bogen 2003 E-mail: Info@HealthCIO.com www.healthcio.com Accelerating HIPAA
Chapter 15 The Electronic Medical Record 8 th edition 1 Lesson 15.1 Introduction to the Electronic Medical Record Define, spell, and pronounce the terms listed in the vocabulary. Discuss the presidential
CONSUMER INFORMATION SHEET 13 September 2012 Is a Personal Health Record Right for You? Considerations for Californians This information is meant to give you an overall picture of Personal Health Records
Patients First: How We Protect Your Privacy To Our Patients: At Northwestern Memorial Hospital, we are committed to providing you with the highest quality of care in an environment that protects your privacy
HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 Mobile Physician Group PC 231 High Street Suite 1, Mount Holly, NJ 08060 1-855-MPG-DOCS THIS NOTICE DESCRIBES
Contents UNIVERSITY OF CHICAGO ALUMNI & DEVELOPMENT DATABASE (GRIFFIN) DATA AND USER ACCESS POLICIES Approved by the Griffin Steering Committee 2/1/07 What is Griffin? Griffin Policies & Procedures Your
Discard Create Inactive Life Cycle of Records Current Retain Use Semi-current Records Management Policy April 2014 Document title Records Management Policy April 2014 Document author and department Responsible
Health Information Technology Courses Course ID Course Title Credits HIT-100 Introduction to Healthcare 3 HIT-110 Medical Terminology I 3 HIT-120 Medical Terminology II 3 HIT-130 Medical Transcription/Editing