UCLA Prominent Patients Medical Record Handling Division:Clinical Data Management Trainer: Pearl G. DurandHealthCare Capstone Contractual Services/ MHA 690 Professor Sherry Grover March 23, 2012 HIPAA Compliance Division
UCLA HospitalUCLA Prominent PatientsMedical 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).
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%
UCLA Prominent Patients Medical Record Handling Zero Tolerancefor Non-Compliancy to HIPAA Rules and Regulations. Termination for Repeat Offenders (Case by Case Basis)
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
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 localprovider community or payer review basis.ACMQ.org. (2010).
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
UCLA Prominent Patients Medical Record Handling Media HandlingAny questions in regards to celebrity patients should only be handled by trained individuals in healthcare public relations departments authorized by hospital.
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.
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.
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
UCLA Prominent Patients Medical Record Handling ReferencesUCLA Health System. (2011). About Ronald Reagan UCLA Medical Center. Retrieved from http://www.uclahealth.org/body_med.cfm?id=346NYU 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-admissionsACMQ.org. (2010). Standard of Care. Retrieved from http://www.acmq.org/policies/policies3and4.pdf
UCLA Prominent Patients Medical Record HandlingQuestions & Answers Session For future assistance pleasecontact Ms. Durand @ 800-1212-1313