UW Medicine Definition, Retention, and Disclosure of the Legal Medical Record
|
|
|
- Philomena Cobb
- 8 years ago
- Views:
Transcription
1 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, Retention, and Disclosure of the Legal Medical Record Policy Number: Date Established: 8/1/2009 Date Revised: 7/12/2013, 03/05/2012, 08/01/2009 Date of Last Cyclic Review: 7/12/2013 Purpose The legal medical record (LMR) is the term used to identify what healthcare information constitutes the medical center s official business record. The LMR is the set of records typically used when responding to formal requests for information for legal and legally permissible purposes and also includes that which complies with accreditation and professional practice standards. The legal medical record (LMR) is the collection of information concerning the care provided to a patient that is created and maintained in the regular course of business, created by workforce members authorized to document in the patients record, who have knowledge of the acts, events, conditions, opinions or diagnoses relating to the patient, and made at or around the time indicated in the documentation. The LMR may contain information received from third parties. Policies and procedures governing the LMR are designed to produce an LMR that meets the standards of reliability necessary for patient care, business, legal and evidentiary purposes. The LMR may include records maintained in an electronic clinical system or the health information/document management system that integrates data from multiple sources, including paper and that captures data at the point of care, and supports caregiver decision making. Historically at the medical centers, there was a distinct paper medical record which contained all documents bound together with covers. Prior to electronic medical record systems, the paper bound record provided distinction and comprised the legal medical record. Portions of our electronic medical record are located in various electronic systems but come together in one or more repositories. UWM entities typically have a hybrid system that has transformed with electronic medical record components. Because of this it has become necessary to identify and define the components which 1
2 comprise the legal medical record. Each LMR will contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. Definitions Business record: A record 1. Created and kept in the regular course of business; 2. Of an act, condition, or event; 3. Made at or near the time of the act, condition, or event 4. In a manner indicating trustworthiness or reliability.2 Hybrid medical record environment: When the legal medical record is created and managed in various formats (such as paper and electronic formats) rather than in one format. Legal medical record: The legal medical record (LMR) is generated at or for a healthcare organization as its business record and is the record that is released upon request. It does not affect the discoverability of other information held by the organization. The custodian of the LMR is health information management (HIM) in collaboration with information technology personnel. HIM professionals oversee the operational functions related to collecting, protecting, and preserving the LMR, while information technology manages the technical infrastructure of the electronic medical record. The LMR is a formally defined legal business record for a healthcare organization. The LMR is individually identifiable data in any medium, collected and used in documenting healthcare or health status. Source systems: The systems in which data was originally created. Primary source system: An information system that is part of the overall clinical information system in which documentation is most commonly first entered or generated. Source of legal medical record: The storage system where the legal medical or health record is held. Policy The UW Medicine (UWM) entities that create medical records (Harborview Medical, rthwest Hospital & Medical,, UW Medical, UW Neighborhood Clinics and our affiliate, Seattle Cancer Care Alliance) will 2
3 create and maintain patient medical records that, in addition to their primary intended purpose of clinical and patient care use, will also serve the business and legal needs of those entities. Medical records for patients over the age of 18 will be retained for a period of no less than ten years following the last provision of health-related services. Medical records for patients under the age of 18 will be retained for a period of no less than 10 years after the last provision of health-related services and 3 years after patient attains the age 18, in order to support patient care, research and to comply with licensing and regulatory requirements. Procedure A. Each UWM entity maintains a medical record for all patients, both inpatient and outpatient, who receive health care services. Medical records for patients over the age of 18 will be retained for a period of no less than ten years following the last provision of health-related services. Medical records for patients under the age of 18 will be retained for a period of no less than 10 years after the last provision of health-related services and 3 years after patient attains the age 18. Each entity shall maintain a document which outlines the components contained in the electronic medical record and is considered part of the legal medical record. These are the documents that are included in the disclosure of the legal medical record. The list of elements will be maintained by HIM and will change over time as the electronic medical record (EMR) develops. B. When a request for the complete medical record is received for evidentiary purposes, the elements in the approved list will be provided as the legal medical record, unless the requester directs a smaller set of records to be provided. For other requesters it is customary to provide a sub set of pertinent records. This is due to the extremely high number of pages that a medical record may contain, which are generally not needed unless the intention for the all-inclusive legal medical record is clearly delineated. Secondary Medical Information (SMI) It is recognized that each entity has other protected health information (PHI) that has traditionally not been kept as part of the medical record. It is protected with the same degree of confidentiality as the medical record. The retention of SMI may vary from that of the LMR. SMI is available for legal purposes and is produced upon a specific request for a specific type of information. There is no centralized list for this information so it is not possible to respond to a general request for all secondary medical information. Examples include: 1. Patient-identifiable Source Data that is not included in the LMR in the absence of an interpretation or summarization of the data, such as: a. Data from which interpretations and summaries are derived. b. Data maintained in a clinical department information system or database. c. Photographs for identification purposes only, audio of dictation, some tracings, some videos/pictures of a procedure. Some source data, such as audio of dictation, is not maintained once it has been converted to text. 2. Administrative data is not considered part of the LMR, such as: 3
4 a. Patient-identifiable data used for administrative, regulatory, healthcare operations and payment purposes (such as an admission list or patient schedule). b. Other examples of Administrative data include: correspondence concerning release of information, event history/audit trails, and data reviewed for quality or utilization management. 3. Derived Data is not considered part of the LMR, such as: a. Information aggregated or summarized from patient records. b. Accreditation and regulatory reports, data for research purposes, public health records, statistical reports, etc. c. Legal correspondence. 4. Under certain circumstances, research may be included in the medical record. See Attachments for a list of source systems. Attachments: List of Entity Specific Source Systems rthwest Hospital & Medical Harborview & UW Medical (includes Seattle Cancer Care Alliance) UW Neighborhood Clinics Hall Health Airlift rthwest Siemens/Soarian ehim Paper Cerner/ORCA Radiology RIS Epic Prelude Historical Paper Chartmaxx Paper Inventory of Source Systems - Secondary Medical Information Reference UWM Administrative Policy & Procedure-HIM Policy 1 Definition, Retention, and Disclosure of the Legal Medical Record UWM Entity Department Name System Name Interpretation/Summary available in EMR system? Harborview & UW Anesthesia Docusys Yes Medical UW Medical Cardiology Verisys Yes although images are Echocardiology (name?) kept in this system Yes although images are kept in this system 4
5 UW Medical /Seattle Cancer Care Alliance Harborview & UW Medical Harborview, UW Medical, rthwest Hospital & Seattle Cancer Care Alliance Digestive Disease/Gastroenterology EndoPro Yes although images are kept in this system Pathology PowerPath by Sunquest Yes Radiology PACS & RIS Orders & Images stored in RIS/PACS All Clinical Departments Paper records although there is a project to implement scanning of paper documentation into ORCA underway Yes are stored Radiation Oncology IMPAC/Mosaiq Yes UW Medical Pain Roosevelt System where images UW Medical /Seattle Cancer Care Alliance & Valley Medical UW Medical Transplant Surgery MAX Yes Harborview & UW OR McKesson Yes Medical UW Medical Infection Control TheraDoc Yes UW Medical Pediatrics Neodata Some notes copied Harborview Medical Cardiology Echocardiography MINDscape UW Medical Laboratory Flow cytometry Yes UW Medical Neurology EMG and NCS Yes UW Medical Pulmonary Pulmonary Function Yes Tests UW Medical Cardiology King of Hearts Harborview & UW Medical Radiology Outside imaging reports Viewable in PACS but not radiology tab UW Medical Cardiology ECG Preliminary ECGs not in ORCA Harborview, UW Medical, Valley Medical Lab Sunquest Yes Harborview Medical & UW Medical Ophthalmology Symphony, images only All Financial documentation pre Oct 2012 Birthcenter (pre Oct 2012) Fetal monitor strips and some notes Emergency Department (pre Oct 2012 Radiology Charge capture and dictation reports copy Billing of network accounts Clinic McKesson Star CPN/QS MedHost Midas Mysis Yes 5
6 rthwest Hospital & rthwest Hospital & Network pre Jul 2012 Birthcenter Fetal Monitor strips (post Oct 2012)-Valley Ambulatory Clinics (not all) OBIX Allscripts Roles and Responsibilities Process Owner: Sally Beahan Date: 07/16/2013 Medical Director: Chief Health System Officer: Thomas Staiger, MD Johnese Spisso Date: 07/16/2013 Date: 07/19/2013 References [1] RCW [2] Chapter 5.45 RCW ( Uniform business records as evidence act ) and ER 803. [3] RCW Approvals Johnese Spisso 7/19/2013 _ Policy Approved By Date 6
![System Officer: Thomas Staiger, MD Johnese Spisso Date: 07/16/2013 Date: 07/19/2013 References [1] RCW 70.41.190. [2] Chapter 5.](/docs-images/43/5455864/images/page_6.jpg "45 RCW ( Uniform business records as evidence act ) and ER 803. [3] RCW 70.41.190.")
LEGAL HEALTH RECORD: Definition and Standards
LEGAL HEALTH RECORD: Definition and Standards DEVELOPING YOUR STRATEGY & Tool Kit Diane Premeau, MBA, MCIS, RHIA, RHIT, CHP, A.C.E. OBJECTIVES Define Legal Health Record Differentiate between Designated
North Shore LIJ Health System, Inc. Facility Name
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
Date Revised: January 25, 2008; January 23, 2009; March 17, 2010; January 7, 2011; February 27, 2012; July 30, 2013 Date of Last Cyclic Review:
Policy Level: Policy Title: Policy Number: UW Medicine Compliance PP-20a - Access Management 20a Date Established: September 28, 2007 Date Revised: January 25, 2008; January 23, 2009; March 17, 2010; January
Regulatory Compliance Policy No. COMP-RCC 4.17 Title:
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)
Guidelines for Defining the Legal Health Record for Disclosure Purposes
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
Resident/Fellow Moonlighting Policy
University of Washington School of Medicine Effective: 02/08/2007; Revised: 7/2009, 8/08/2013 Graduate Medical Education Page 1 of 7 Resident/Fellow Moonlighting Policy Scope: This policy applies to Residents
UW Medicine Northwest Hospital & Medical Center. Implementation Strategy
UW Medicine Northwest Hospital & Medical Center Implementation Strategy 2013 Implementation Strategy Introduction Northwest Hospital & Medical Center is a component of the UW Medicine Health System. The
UW Medicine Case Study
Learn Serve Lead April 2013 Association of American Medical Colleges ABOUT THE BEST PRACTICES FOR BETTER CARE CASE STUDY SERIES Better performers from the Best Practices for Better Care initiative, identified
Integrating a PACS/Imaging System into an EHR Anwar Motan John Riggs, MD
Integrating a PACS/Imaging System into an EHR Anwar Motan John Riggs, MD DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official
Defining the Core Clinical Documentation Set
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
Managing Images Across the Enterprise. Kim Garriott & Louis Lannum July 30, 2015
Managing Images Across the Enterprise Kim Garriott & Louis Lannum July 30, 2015 Objectives Summarize what an enterprise imaging strategy is and address key components Discuss the role of Clinical Engineering
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION Hospital Policy Manual Purpose: To define the components of the paper and electronic medical record
Clinical Research Management Training Program Electronic Medical Records: Access, Use and Compliance for Research March 11, 2013
Clinical Research Management Training Program Electronic Medical Records: Access, Use and Compliance for Research March 11, 2013 Linda Metro, RHIA Director, Health Information Management Electronic Medical
North Division Telephone Directory
MONTEFIORE MEDICAL CENTER NORTH DIVISION 600 E. 233 RD STREET BRONX, NEW YORK 10466 North Division Telephone Directory (When calling internally, use all five digits of the extension. When calling from
ICD-10 Implementation Project Webinar 1
ICD-10 Implementation Project Webinar 1 Review of Vendor Worksheet Results Project Update Wednesday, August 14, 2013 John Behn MPA 1 Agenda Review Participating Facilities Steering Committee Calls Outstanding
Contents: Centers for Medicare/Medicaid (CMS) Clinical Trials Policy (CTP) Training. CMS CTP Background, Definitions and Requirements
Contents: CMS CTP Background, Definitions and Requirements Process Going Forward UW Medicine Process Reminders April 2009, Slide 1 Background: In 2000, Medicare issued a National Coverage Decision (NCD)
The Physician Quality Reporting Initiative: Using Information Technology to Advance Quality of Care
The Physician Quality Reporting Initiative: Using Information Technology to Advance Quality of Care Joseph Cooke, MD; Chief Quality and Patient Safety Officer Mary Koval, RN; Clinical Quality Program Manager
SHADY GROVE ADVENTIST HOSPITAL DEPARTMENT OF MEDICINE CARDIOLOGY SECTION RULES AND REGULATIONS
DEPARTMENT OF MEDICINE I. Purpose A Cardiology Section, within the Department of Medicine will be established pursuant to Article X, Section 7 of the Bylaws of the Medical Staff. This action is taken primarily
Clinical Trial Center
Clinical Trial Center QUALITY The mission of the Clinical Trial Center (CTC) is to facilitate the timely execution of quality clinical trials with information, resources and expertise in order to foster
Teaching Physician Billing Compliance. Effective Date: March 27, 2012. Office of Origin: UCSF Clinical Enterprise Compliance Program. I.
Teaching Physician Billing Compliance Effective Date: March 27, 2012 Office of Origin: UCSF Clinical Enterprise Compliance Program I. Purpose These Policies and Procedures are intended to clarify the Medicare
Enterprise Imaging. Moving Beyond Traditional PACS
Enterprise Imaging Moving Beyond Traditional PACS DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position
POLICY PRINCIPLES/STATEMENT
Applicability: Policy Title: Policy Number: Identity Theft Prevention PP-31 Superseded Policy(ies) or Entity Policy: N/A Date Established: August 1, 2009 Date Effective: March 1, 2015 Dates Revised: December
Ambulatory EMR Implementation at Texas Children s Hospital. GE Healthcare User Summit September 23, 2004
Ambulatory EMR Implementation at Texas Children s Hospital GE Healthcare User Summit September 23, 2004 1 About TCH Texas Children s Hospital (TCH) is the largest pediatric hospital in the U.S., with licensing
Record Custodian to Health Information Steward Best Practices in Record Retention, Storage, and Destruction
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
APPENDIX CONFLICT OF INTEREST CODE OF THE COUNTY OF SANTA CLARA EXHIBIT A LIST OF DESIGNATED POSITIONS FOR
APPENDIX CONFLICT OF INTEREST CODE OF THE COUNTY OF SANTA CLARA EXHIBIT A LIST OF DESIGNATED POSITIONS FOR SANTA CLARA VALLEY HEALTH & HOSPITAL SYSTEM Designated Position Community Health Services Health
Physician Practice Acquisitions
Trend Watch: Physician Practice Acquisitions Tracking Which Physician Practices Hospitals are Acquiring Introduction Are hospitals actively acquiring physician practices? If so, which specialties? In this
SUNY RECORDS RETENTION AND DISPOSITION SCHEDULE
(in student health centers, hospitals, long term care, rehabilitation and home health agencies) NOTE: Paper records may be destroyed after scanning or microfilming, with digital and microfilm versions
EMR UPDATE ON TIME AND ON BUDGET CLINICAL TRANSFORMATION IMPLEMENTATION PLAN
EMR UPDATE ON TIME AND ON BUDGET CLINICAL TRANSFORMATION IMPLEMENTATION PLAN Testing and Build Stability View Only Scanning Interfaces Training Innovative Technology EMR UPDATE COMMUNICATION PLAN Essential
ColumbiaDoctors, the Physicians and Surgeons of Columbia University define the health record as follows:
Definition ColumbiaDoctors, the Physicians and Surgeons of Columbia University define the health record as follows: A hybrid health record for patients seen in the private practice setting that includes
Administrative Policies and Procedures POLICY FOR USE AND ACCESS TO ENTERPRISE DATA CENTER FACILITIES
Administrative Policies and Procedures POLICY FOR USE AND ACCESS TO ENTERPRISE DATA CENTER FACILITIES Department: Information Technology Services Policy Number: Effective Date: Revision Date: June 11,
How to Conduct a Thorough CAC Readiness Assessment
WHITE PAPER How to Conduct a Thorough CAC Readiness Assessment A White Paper from Nuance Healthcare HEALTHCARE COMPUTER-ASSISTED CODING Contents Introduction... 3 The Benefits of CAC... 4 The New Role
UW MEDICAL CENTER ELECTRONIC HEALTH RECORD BENEFITS & CHALLENGES
UW MEDICAL CENTER ELECTRONIC HEALTH RECORD BENEFITS & CHALLENGES Sally Beahan, RHIA, MHA Director, Health Information Management October 28 2009 Choosing the System One size fits all approach System to
Regulatory Compliance Policy No. COMP-RCC 4.07 Title:
I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.07 Page: 1 of 7 This policy applies to (1) any Hospital in which Tenet Healthcare Corporation or an affiliate owns a direct or indirect equity interest
MGMA PROVIDER COMPENSATION 2015
Physicians Allergy/Immunology 203 86 Anesthesiology 2,146 120 Anesthesiology: Pain Management 127 59 Cardiology: Electrophysiology 327 126 Cardiology: Invasive 424 148 Cardiology: Invasive-Interventional
Evolving UM SOM Clinical Practice as the Healthcare Environment Changes
Evolving UM SOM Clinical Practice as the Healthcare Environment Changes Introduction to the UM SOM Medical Service Plan This section will cover the following elements: 1. FPI creation, organization, and
VACAVILLE MEDICAL CENTER. Staff Navigator
VACAVILLE MEDICAL CENTER Staff Navigator VACAVILLE MEDICAL CENTER Hospital VACAVILLE MEDICAL CENTER - Hospital Department Floor Bldg Pg Administration - HIMS 4 H 9 Admitting 1 H 6 Bed Repair B H 5 Cafeteria
UWMC Floor Maps. for Patients and Visitors October 2012 FLOOR SURGERY PAVILION MAIN HOSPITAL. (1st Floor) (1st Floor) NOTES KEY.
1 111 Specialty Clinic at * To Montlake Cut S-1 For wheelchair to S1, take the elevator to Basement. Use Montlake 1st floor elevator to : Neonatal Intensive Care (4th floor) Inpatient Oncology (8th floor)
(A) Information needed to identify and classify the hospital, include the following: (b) The hospital number assigned by the department;
3701-59-05 Hospital registration and reporting requirements. Every hospital, public or private, shall, by the first of March of each year, register with and report to the department of health the following
Moses Telephone Directory
MONTEFIORE MEDICAL CENTER THE HENRY AND LUCY MOSES DIVISION 111 EAST 210TH STREET BRONX, NEW YORK 10467 Moses Telephone Directory (When calling from the outside use 920 before extension) NUMBER TIE-LINE
Case Study: Using Predictive Analytics to Reduce Sepsis Mortality
Case Study: Using Predictive Analytics to Reduce Sepsis Mortality 1 Learning Objectives 1. Understand how an automated, real time IT intervention can help care teams recognize and intervene on critical,
Chapter 4 Health Care Management Unit 1: Care Management
Chapter 4 Health Care Unit 1: Care In This Unit Topic See Page Unit 1: Care Care 2 6 Emergency 7 4.1 Care Healthcare Healthcare (HMS), Highmark Blue Shield s medical management division, is responsible
DETROIT MEDICAL CENTER DEPARTMENT OF PEDIATRICS DELINEATION OF PRIVILEGES IN PEDIATRIC CARDIOLOGY. Applicant Name PLEASE PRINT QUALIFICATIONS:
DETROIT MEDICAL CENTER DEPARTMENT OF PEDIATRICS DELINEATION OF PRIVILEGES IN PEDIATRIC CARDIOLOGY QUALIFICATIONS: Current Board Certification or active participation in the certification process leading
CAROLINAS REHABILITATION
CAROLINAS REHABILITATION CURRENT LANGUAGE ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) New Language ORGANIZATIONAL MANUAL OF BYLAWS OF CAROLINAS REHABILITATION (TAB 2) ARTICLE II
Use & Disclosure of Protected Health Information by Business Associates
Applicability: Policy Title: Policy Number: Use & Disclosure of Protected Health Information by Business Associates PP-12 Superseded Policy(ies) or Entity Policy: N/A Date Established: January 31, 2003
METROWEST MEDICAL CENTER
(508) 650-7000 Framingham Union METROWEST MEDICAL CENTER 115 Lincoln Street (508) 383-1000 24-hour Emergency Department Care Community Healthcare Provider This healthcare network encompasses the entirety
Project Management Panel
Project Management Panel INTRODUCTIONS OF PANELISTS Jennifer Baguisa Approaching 15 years in IT Project Management Project Management Professional since 2007 Business background is Life Insurance New to
Use & Disclosure of Protected Health Information Related to Inpatient Facility Directories & for Disaster Relief Purposes
Applicability: Policy Title: Policy Number: Use & Disclosure of Protected Health Information Related to Inpatient Facility Directories & for Disaster Relief Purposes PP-13 Superseded Policy(ies) or Entity
Litigation Session II 10:45 INTERPRETATION OF MEDICAL RECORDS JANE HERON, RN, BSN, MBA
Litigation Session II 10:45 INTERPRETATION OF MEDICAL RECORDS JANE HERON, RN, BSN, MBA NJ Paralegal Convention October 19, 2012 Looking for clues to what really happened Presented by Jane D. Heron, RN,
AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Verificatoin Criterea EFFECTIVE JANUARY 1, 2015. Criterion. Level (1 or 2) Number
Criterion AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Criterion Level (1 or 2) Number Criterion BURN CENTER ADMINISTRATION 1. The burn center hospital is currently accredited by The
CMS Data What s In It & How To Use It. Kimberly Kauffman Executive Director Summit Health Solutions
CMS Data What s In It & How To Use It Kimberly Kauffman Executive Director Summit Health Solutions 2 Summit Health Solutions ACO w/ July 1, 2012 start date Wholly owned by Summit Medical Group Two hospital
Meditech Scanning & Archiving
Meditech Scanning & Archiving Overview Effective November 14, 2012, Children s Hospital will go-live with Meditech Scanning & Archiving. Documents will no longer be scanned in ChartMaxx. Exception: Orders
ALASKA. Downloaded January 2011
ALASKA Downloaded January 2011 7 AAC 12.255. SERVICES REQUIRED A nursing facility must provide nursing, pharmaceutical, either physical or occupational therapy, social work services, therapeutic recreational
E-Discovery: A Deposition for your Electronic Health Record
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
i-care Integrated Hospital Information System
i-care Integrated Hospital Information Empowering Healthcare Through Integrated Information and Intelligence Iterum TM i-care Hospital Information (HIS) provides a comprehensive and integrated solution
NOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can access this information. Please read it carefully. If you have any questions,
DRAFT. Select VHA ENTERPRISE STANDARD TITLE:??
Select VHA ENTERPRISE STANDARD TITLE:?? Choose from: ACUPUNCTURE CONSULT ACUPUNCTURE NOTE ADDENDUM ADDICTION PSYCHIATRY ADDICTION SEVERITY INDEX NOTE ADDICTION PSYCHIATRY ADMINISTRATIVE NOTE ADDICTION
PURPOSE AND SCOPE This table is applicable to all UW Medicine Compliance Policies governing privacy.
Applicability: Policy Title: Policy Number: Glossary of s PP-00 Superseded Policy(ies) or Entity Policy: N/A Date Established: October 27, 2003 Date Effective: September 21, 2015 Dates Revised: November
Demonstration Study of Healthcare Utilization by Obese Patients. Joseph Vasey PhD Director, Epidemiology Quintiles Outcome May 22, 2013
Demonstration Study of Healthcare Utilization by Patients Joseph Vasey PhD Director, Epidemiology Quintiles Outcome May 22, 2013 Copyright 2013 Quintiles Revised April 2013 Introduction Obesity in the
1. What is your name? Last name First name Middle Initial Degree(s)
Version: 6122008 Rhode Island Health Care Quality Performance (HCQP) Program This survey asks about physicians' use of health information technology (HIT) and should take less than 10 minutes to complete.
Who is looking at your electronic health record?
Who is looking at your electronic health record? A practical guide to building an audit plan. April 22, 2013 Sandy Gilmore Audit Plan April 2013 2 1 Audit Plan April 2013 3 Who is looking at your EHR Objectives
Joint Commission International Accreditation Standards for Ambulatory Care
Effective 1 January 2015 Joint Commission International Accreditation Standards for Ambulatory Care English 3rd Edition Section I: Accreditation Participation Requirements JOINT COMMISSION INTERNATIONAL
PHYSICIAN ASSISTANT. Education and Practice Donna DeGracia MPAS, PA-C St. Catherine University MPAS Program
PHYSICIAN ASSISTANT Education and Practice Donna DeGracia MPAS, PA-C St. Catherine University MPAS Program History of PA Profession Started in the mid 1960s to address shortage of primary care physicians
Health Information. Technology and Cancer Information Management. Health Information Technology & Cancer Information Management 363
Health Information Technology & 363 Health Information Technology and Cancer Information Management Opportunities in the health information field have expanded with changes in health care delivery, utilization
Timothy F. Hawkins 114 NW 27 PL Cape Coral, Fl 33993 865-368-2106
Curriculum Vitae Timothy F. Hawkins 114 NW 27 PL Cape Coral, Fl 33993 865-368-2106 EDUCATION: 2011 ACLS Certification 2001 FAA Certified IFR Pilot 1996 Licensed General Contractor (Florida) 1984 MBA, University
Not Just Another Checklist: Using Technology to Implement the Time- Out in the Non-OR Setting
Not Just Another Checklist: Using Technology to Implement the Time- Out in the Non-OR Setting Ross Ehrmantraut, RN, CCRN Patient Safety Officer Liz McNamara, RN, MN Clinical Operations Manager for Infection
State of Bahrain Ministry of Health Salmaniya Medical Complex
State of Bahrain Ministry of Health Salmaniya Medical Complex A Handbook January 2001 Appendix Purpose. 3 Introduction. 4 Specialties available at S.M.C. 5 Outpatient Policies and Procedures Source of
CLINICAL & FINANCIAL BENEFITS OF ECG MANAGEMENT
How Will an ECG Management System with Electronic Storage and Recall Benefit my Facility? ECG management has been available in the industry for over twenty- five years. Until now it has been both expensive
Diagnostic Imaging Management
Diagnostic Imaging Management Frequently Asked Questions (FAQ) from Providers Updated August 1, 2013 Program Overview Q1. What is AIM Specialty Health SM (AIM)? A1. AIM Specialty Health SM (AIM) is a leading
A technology-enabled business model
A technology-enabled business model for delivering healthcare Thomas Nesbitt, M.D., M.P.H. Executive Associate Dean School of Medical, Director Center for Health and Technology University of California
2002 Physician Inpatient/Outpatient Revenue Survey
2002 Physician Inpatient/Outpatient Revenue Survey INTRODUCTION: Merritt, Hawkins & Associates is a national physician search and consulting firm representing over 2,000 physician search engagements annually.
BASIC STANDARDS FOR RESIDENCY TRAINING IN CARDIOLOGY
BASIC STANDARDS FOR RESIDENCY TRAINING IN CARDIOLOGY American Osteopathic Association and the American College of Osteopathic Internists Specific Requirements For Osteopathic Subspecialty Training In Cardiology
WENATCHEE VALLEY MEDICAL CENTER
WENATCHEE VALLEY MEDICAL CENTER Greater Wenatchee Patient population of 235,000 Collegial communication is a hallmark of our practice High-tech information systems include EMR, PACS, fiber-optic network,
THE CHALLENGE OF COORDINATING EMR
THE CHALLENGE OF COORDINATING EMR CLINICAL CONNECT: TWO YEARS OF REGIONAL ELECTRONIC HEALTH INFORMATION EXCHANGE NANCY A. LANDMAN, CIO INTERNATIONAL & COMMERCIAL SERVICES, UPMC 10/8/2014 2 UPMC Today:
Laboratory Radiology Pathology Dictation
Web portals EMR Overview Electronic Medical Records, University of Colorado Hospital (UCH), June 2010 CT Lin MD ct.lin@ucdenver.edu; Jonathan Pell MD jonathan.pell@ucdenver.edu Provider Portal: MedXplore
Secondary Uses of Health Data IMPAC s Oncology Data Alliance Program
Secondary Uses of Health Data IMPAC s Oncology Data Alliance Program NCVHS August 1, 2007 Joel Goldwein, MD Senior Vice President, Medical Affairs IMPAC Medical Systems Inc. IMPAC Medical Systems, Inc.
PARCA Certified PACS System Analyst (CPSA2014) Requirements
PARCA Certified PACS System Analyst (CPSA2014) Requirements Copy right notice: Copyright 2014 PACS Administrators in Radiology Certification Association (PARCA). All rights reserved. All rights reserved.
Long-Term Clinical Service Plan Impacts for 2016/17. October 2015
Long-Term Clinical Service Plan Impacts for 2016/17 October 2015 1 Purpose 1. Ensure common understanding of what is driving change Health System Funding Reform, QHC cost structure issues 2. Share significant
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
COVER SHEET NAME OF DOCUMENT Hybrid Health Care Record Procedure TYPE OF DOCUMENT Procedure DOCUMENT NUMBER SESLHDPR/292 DATE OF PUBLICATION September 2013 RISK RATING Low LEVEL OF EVIDENCE N/A REVIEW
Appendix II - Outpatient settings worksheets
Key Policy Elements for Best Appendix II - Outpatient settings worksheets The following worksheets are intended to increase awareness within public health agencies of the authorities currently in place
TITLE: SHARED EMR LEGAL HEALTH RECORD GUIDANCE
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 2 HEALTH INFORMATION SYSTEMS
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
Microsoft Amalga HIS Hospital Information System 2009
m Microsoft Amalga HIS Hospital Information System 2009 Manage all healthcare organisation functions with one integrated solution Microsoft AmalgaTM Our vision: To improve health around the world through
Microsoft Amalga Hospital Information System (HIS)
m Microsoft Amalga Hospital Information System (HIS) > Manage all hospital functions with one integrated solution PG 0 Our Vision: To improve health around the world For more than a decade, Microsoft has
MedStar Ambulatory Care EHR Dawn Richmond IS Ambulatory EHR Manager
MedStar Ambulatory Care EHR Dawn Richmond IS Ambulatory EHR Manager TOPICS MedStar Overview Ambulatory EHR Implementation Mission/Goals Strategy Scope Governance / organizational structure Timeline/Status
2 nd Floor CS&E Building A current UMHS identification badge is required to obtain medical records
Location Hours 2 nd Floor CS&E Building A current UMHS identification badge is required to obtain medical records The Health Information Services Department is open to the public Monday through Friday,
E-Discovery: A Deposition for your Electronic Health Record
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,
SCHEDULING GUIDE. April 15, 2016. FOR CHANGES TO THE SCHEDULING DIRECTORY, PLEASE EMAIL gainer@musc.edu.
SCHEDULING GUIDE April 15, 2016 FOR CHANGES TO THE SCHEDULING DIRECTORY, PLEASE EMAIL gainer@musc.edu. Service Telephone Fax Adolescent Medicine 876-0444 876-1493 Allergy & Immunology 876-8282 876-8181
PLASTIC SURGERY RESIDENTS HANDBOOK
PLASTIC SURGERY RESIDENTS HANDBOOK I. PLASTIC SURGERY REQUIREMENTS a. AACPS Post Interview Communication Guidelines b. General Competencies c. Plastic Surgery Goals & Objectives d. ACGME Required Index
Medical Transcriptionist Online
Education & Training Plan Medical Transcriptionist Online MyCAA Information Tuition: $3200 (RMT- AHDI exam included) MyCAA Course Code: LIT-MT2 Course Contact Hours: 185 Hours Program Duration: 3 Months
2013 Physician Inpatient/ Outpatient Revenue Survey
Physician Inpatient/ Outpatient Revenue Survey A survey showing net annual inpatient and outpatient revenue generated by physicians in various specialties on behalf of their affiliated hospitals Merritt
Insert Presentation Name
Insert Presentation Name Presentation to: Presented by: Date: 1 Title or Chapter Slide One patient, One record (use as needed; feel free to delete) A Journey Praveen Chopra, CPIM VP, Chief Information
Legal EHR Policy Template Developed by Members of the EHR Practice Council May 2007
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
Elenco dei periodici elettronici in Ovid Full text
Academic Medicine Addictive Disorders & Their Treatment Advances in Anatomic Pathology Age & Ageing AIDS AIDS Patient Care & Stds AJN, American Journal of Nursing Alzheimer Disease & Associated Disorders
Bringing together all of the cardiovascular information you need into a single platform
Care Providers Hospitals Enterprise Image and Information Bringing together all of the cardiovascular information you need into a single platform Organizations want to improve quality of care, boost efficiencies
WHAT S CANCER GOT TO DO WITH FOOD?
For Immediate Release 4 February 2015 WHAT S CANCER GOT TO DO WITH FOOD? Food is a major element in cancer prevention and care. Not only can cancer risk be reduced with a healthy lifestyle; nutritional
REQUEST FOR MEMBERSHIP AND CLINICAL PRIVILEGES
REQUEST FOR MEMBERSHIP AND CLINICAL PRIVILEGES *Applicant Printed Name: *Denotes required fields (Last) (First) (M.I) (Degree) Maiden Name (Alias): (Last) (First) *DOB: *SSN Sex: Male Female *Applicant
Documentation Guidelines for Physicians Interventional Pain Services
Documentation Guidelines for Physicians Interventional Pain Services Pamela Gibson, CPC Assistant Director, VMG Coding Anesthesia and Surgical Divisions 343.8791 1 General Principles of Medical Record
Hackensack University Medical Center Administrative Policy Manual. Effective Date: January 2016 Page 1 of 11
Policy #: 1845 Hackensack University Medical Center Administrative Policy Manual Effective Date: January 2016 Page 1 of 11 Purpose: To identify the governing rules for the collection of all fees associated
REPORT TO THE 2015 LEGISLATURE. Report on Findings from the Hawai i Physician Workforce Assessment Project
REPORT TO THE 2015 LEGISLATURE Report on Findings from the Hawai i Physician Workforce Assessment Project Act 18, SSLH 2009 (Section 5), as amended by Act 186, SLH 2012 January 2015 Hawai i Physician Workforce
Business Loan Insurance Plan Critical Illness Claim - Policy 57903
Business Loan Insurance Plan Critical Illness Claim - Policy 57903 RBC use only Before submitting a critical illness claim: Complete and sign the Claimant s Statement for your critical illness. Please