1. UCLA Prominent Patients
Medical Record Handling
Division:
Clinical Data Management
Trainer:
Pearl G. Durand
HealthCare Capstone Contractual
Services/ MHA 690
Professor Sherry Grover
March 23, 2012
HIPAA Compliance Division
2. UCLA Hospital
UCLA Prominent Patients
Medical Record Handling Mission Statement:
Compliance Call to Action
Issues to be discussed To provide excellent
1. HIPAA Fines patient care
2. Zero Tolerance in support of the
3. “ Oath to do no educational and
Harm”
4. “Standard of Care” scientific programs of
5. Quality standard the schools of the UCLA
6. Patient Privacy Center for the Health
7. Patient
Confidentiality Sciences
(UCLA Health System, 2011).
3. UCLA Prominent Patients
Medical Record Handling
HIPAA Law-Fines
• HIPAA Security: Harsh
Fines, Penalties Are a
Wake-up Call to Us All
• $1-million fine
• Corrective action plan
• Unauthorized patient file
access = violation of the
HIPAA Privacy Rule
• Requirements to develop
comprehensive policies and
procedures
• Cause and Effect
HIPAA compliance- “Mandatory” 100%
4. UCLA Prominent Patients
Medical Record Handling
Zero Tolerance
for Non-Compliancy to HIPAA Rules and
Regulations.
Termination for Repeat Offenders
(Case by Case Basis)
5. UCLA Prominent Patients
Medical Record Handling
Standard of Care
“Oath to do no harm- non-malfeasance”
The Standard of Care is a case- and time-specific analytical
process in medical decision-making, reflecting a
clinical benchmark of acceptable quality medical care. This
benchmark, which is used to evaluate and guide the practice
of medicine, encompasses the learning, skill and clinical
judgment ordinarily possessed and used by prudent health
care
providers or payers of good standing in similar circumstances.
The standard of care must reflect the art (consensus of
opinion of clinical judgment) and science (published peer
reviewed literature) of medicine and must be uniform for all
6. UCLA Prominent Patients
Medical Record Handling
Standard of Care Continued
“Oath to do no harm- non-malfeasance”
health care personnel whether they are providing direct
clinical care or reviewing the medical necessity of
past, present or
future medical care. A violation of standard of care may
result in under-utilization of medical care, but also occurs
when
unnecessary care (over-utilization) is provided. The
standard of care has a national and clinical basis, rather
than a local
provider community or payer review basis.
ACMQ.org. (2010).
7. UCLA Prominent Patients
Medical Record Handling
• Quality Standards are Effective Immediately
paramount to the Training
Hospital’s Success
Mandatory 6 months
• Patient Privacy training for all employees
• Patient Confidentiality on HIPAA Guidelines
All media
inquiries/questions
should be directed to our
public service experts
8. UCLA Prominent Patients
Medical Record Handling
Media Handling
Any questions in regards to celebrity patients
should only be handled by trained individuals
in healthcare public relations departments
authorized by hospital.
9. UCLA Prominent Patients
Medical Record Handling
Effective Immediately
Restricted Access
Celebrity patient medical
records will be placed in
special secured files
which have to be
accessed by medical
record director or other
designated persons.
This method helps to
alleviate unauthorized
access of prominent
patient records.
10. UCLA Prominent Patients
Medical Record Handling
Procedures for Supervisors/Medical Records Administration
Handling
• All information released should be approved and released
after being verified to be accurate and consistent. Only
what patient has authorized after review board approves.
• Steps to prevent unauthorized usage and disclosure of
medical information:
• Replacing patient’s name with an alias or coding system
while in the hospital to be placed on bed boards, bulletin
boards and patient room signs.
• Restricted Access and alert system of unauthorized breach
based on clearance level.
11. UCLA Prominent Patients
Medical Record Handling
Procedures for Supervisors/
Medical Records Administration Handling Continued
• Paper Based Records- Assign head nurse as designated person per
shift to access records.
• All employees will undergo nondisclosure training and sign
nondisclosure form.
• Discharge- Restrict access to persons only required to close out file
and follow- up care documentation only.
• Medical Records and the Law
Questions & Answers Session
For future assistance please
contact Ms. Durand @ 800-1212-1313
12. UCLA Prominent Patients
Medical Record Handling
References
UCLA Health System. (2011). About Ronald Reagan UCLA
Medical Center. Retrieved from
http://www.uclahealth.org/body_med.cfm?id=346
NYU Langone Medical Center. (2011).HIPAA Security: Harsh
Fines, Penalties Are a Wake up Call to Us All. Retrieved from
http://compliance.med.nyu.edu/news/documenting-
inpatient-admissions
ACMQ.org. (2010). Standard of Care. Retrieved from
http://www.acmq.org/policies/policies3and4.pdf
13. UCLA Prominent Patients
Medical Record Handling
Questions & Answers
Session
For future assistance
please
contact Ms. Durand @
800-1212-1313
