Examine Legal Requirements For Managing Patient Information

examine Legal Requirements For Managing Patient Information

Examine legal requirements for managing patient information, health information documentation, the release of information, and electronic health records.

You have recently been promoted to Health Services Manager at Three Mountains Regional Hospital, a small hospital located in a mid-size city in the Midwest. Three Mountains is a general medical and surgical facility with 400 beds. Last year there were approximately 62,000 emergency visits and 15,000 admissions. More than 6,000 outpatient and 10,000 inpatient surgeries were performed.

Three Mountains was recently in the news after employee emails were published where patients were discussed in very negative terms. Due to the breach of information, many patients are skeptical about selecting Three Mountains as their hospital of choice. Even though specific names of patients were not disclosed as part of the inappropriate dissemination of information, parts of their medical records were mentioned. The patient information was not shared in a favorable light. Patients want to feel secure when they share information with their healthcare providers and be certain that it will remain private.

You will create an informational brochure educating patients about the contents of the medical record and the proper release of information. In a double-sided brochure, you need to address the following topics: The Electronic Medical Record, HIPAA and Confidentiality, Release of Information, and a Privacy Pledge.

Paper For Above instruction

Creating an effective and comprehensive patient information brochure requires a careful synthesis of legal standards, ethical considerations, and hospital policies regarding health information management. Given recent breaches and public concerns, such a brochure must clearly communicate how patient information is managed, protected, and shared within the healthcare facility.

The Electronic Medical Record: Definition and Contents

An Electronic Medical Record (EMR) is a digital version of a patient's paper chart maintained by healthcare providers. It encompasses the patient's medical history, diagnoses, medications, treatment plans, progress notes, laboratory results, imaging reports, and other relevant health information (HIMSS, 2020). The EMR facilitates accurate documentation, efficient access to information, and improved coordination among healthcare providers. The Joint Commission (2021) emphasizes that entries in the EMR should be completed timely, generally within 24 hours of the patient encounter, ensuring that records are accurate, complete, and reflect the current health status of the patient.

The contents of an EMR include demographic data, history and physical examination findings, diagnostic test results, treatment notes, medication administration records, consent forms, and discharge summaries. Proper documentation is critical not only for quality care but also for legal and billing purposes. The Joint Commission recommends that healthcare providers document their notes meticulously and promptly, as delays can compromise the accuracy and integrity of medical records (Joint Commission, 2021).

HIPAA and Confidentiality

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law designed to protect the privacy and security of patients’ protected health information (PHI). HIPAA establishes standards for safeguarding electronic health information and grants patients rights over their health data, including rights to access, amend, and restrict certain disclosures (HHS, 2020). At Three Mountains Regional Hospital, strict confidentiality protocols are implemented to ensure that patient information remains secure and private.

HIPAA also mandates that healthcare providers only share PHI for authorized purposes, such as treatment, payment, and healthcare operations, unless the patient provides explicit authorization for other disclosures (HHS, 2020). Any breaches or unauthorized disclosures, like the recent email incident, violate HIPAA regulations and compromise patient trust. The hospital’s confidentiality policies uphold the principle that patient information is privileged and individuals have the right to expect that their private health information will be protected at all times.

Release of Information

Patients have the right to access their medical records and request copies or specific sections of their health information. To do so, they must submit a written request to the hospital’s health information management department. The hospital will process the request in accordance with HIPAA regulations, which generally requires providing copies within 30 days, although this can vary depending on state laws or specific circumstances (HIMSS, 2019).

It is essential to note that medical information cannot be shared without the patient’s explicit consent, except in legally permitted situations such as reporting certain communicable diseases or court orders. To maintain privacy, the hospital requires patients to complete a Release of Information form specifying what records they seek and to whom they wish the information to be disclosed. Only authorized personnel will process these requests, ensuring compliance with confidentiality policies and legal standards.

Privacy Pledge

At Three Mountains Regional Hospital, we are committed to safeguarding your health information. Our privacy pledge states: “You can trust that your personal health information will be protected and kept confidential. We follow strict legal and ethical standards to ensure your privacy is maintained, and your information is only shared with your explicit permission and in accordance with the law.” This pledge underscores our dedication to maintaining patient trust and securing sensitive health data.

Conclusion

Protecting patient information is a fundamental aspect of healthcare. By understanding the contents of the EMR, the importance of HIPAA confidentiality requirements, and the procedures for authorizing the release of information, patients can feel more confident in sharing their personal health data. Our hospital's commitment is to uphold the highest standards of privacy, ensuring that your medical information remains secure and that your rights are respected.

References

  • Health Information and Management Systems Society (HIMSS). (2019). Managing requests for medical records. https://www.himss.org
  • U.S. Department of Health & Human Services (HHS). (2020). Summary of the HIPAA privacy rule. https://www.hhs.gov
  • The Joint Commission. (2021). Comprehensive accreditation manual for hospitals. https://www.jointcommission.org
  • U.S. Department of Health & Human Services (HHS). (2020). HIPAA privacy rule and sharing information. https://www.hhs.gov
  • American Health Information Management Association (AHIMA). (2021). Managing health information documentation. https://www.ahima.org
  • Office for Civil Rights. (2020). Breach notification requirements under HIPAA. https://www.hhs.gov/ocr
  • National Committee on Vital and Health Statistics. (2018). Setting standards for medical records. https://www.ncvhs.hhs.gov
  • Office of the National Coordinator for Health Information Technology (ONC). (2020). Guide to electronic health records. https://www.healthit.gov
  • Centers for Disease Control and Prevention (CDC). (2019). Protecting personal health information. https://www.cdc.gov
  • American Medical Association (AMA). (2022). Ethical obligations in health information management. https://www.ama-assn.org

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