This document outlines Ophthalmic Associates of Fort Washington's business associate policy and procedures. It states that the practice will establish business associate agreements with any organization that handles electronic protected health information on its behalf or provides certain services to ensure this information is appropriately safeguarded. The security officer will determine which organizations are considered business associates and require written contracts with them that require reasonable safeguards and security incident notification. Examples of business associates include billing companies, software vendors, transcription services, and medical record storage companies.
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As the effects of reform continue to implement changes to our nation’s health care structure, providers find themselves forced to act quickly amidst the resultant chaos. Nowhere is the confusion more apparent than when it comes to issues of compliance.
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http://craiggarner.com/compliance/.
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Maintaining a Legally Sound Health Record Paper and Elect.docxjessiehampson
Maintaining a Legally Sound Health Record:
Paper and Electronic
The health record is the legal business record for a healthcare organization. As such, it must be maintained in a
manner that follows applicable regulations, accreditation standards, professional practice standards, and legal
standards. The standards may vary based on practice setting, state statutes, and applicable case law. An attorney
should review policies related to legal documentation issues to ensure adherence to the most current standards and
case law.
HIM professionals should fully understand the principles of maintaining a legally sound health record and the potential
ramifications when the record’s legal integrity is questioned. This practice brief will review the legal documentation
guidelines for entries in and maintenance of the health record—both paper and electronic. Many of the guidelines that
originally applied to paper-based health records translate to documentation in electronic health records (EHRs). In
addition, new guidelines and functionalities have emerged specific to maintaining legally sound EHRs. It is of the
utmost importance to maintain EHRs in a manner that will support a facility’s business and legal processes, otherwise
duplicate paper processes will need to be maintained.
AHIMA convened an e-HIM® work group to re-evaluate and update the 2002 practice brief “Maintaining a
Legally Sound Health Record” to address the transition many organizations face in the migration from paper to
hybrid to fully electronic health records. Issues unique to EHRs are addressed specifically if they are different or
require expansion. Many organizations use a hybrid record (which includes both paper and electronic
documentation), scanning paper documents into an electronic document management system. Even though a scanned
document ends up in an electronic state, the documentation principles for paper-based records still apply. If there
are unique issues for scanned records, they are specified in this brief.
Authentication for Legal Admissibility
Generally, statements made outside the court by a party in a lawsuit are considered hearsay and not admissible as
evidence. Documentation in the health record is technically hearsay; however, Federal Rules of Evidence (803(6))
and the Uniform Business and Public Records Act adopted by most states allow exception to the hearsay rule for
records maintained in the regular course of business, including health records. All records must be identified and
authenticated prior to admissibility in court.
Four basic principles must be met for the health record to be authenticated or deemed admissible as evidence. The
record must have been:
� Documented in the normal course of business (following normal routines)
� Kept in the regular course of business
� Made at or near the time of the matter recorded
� Made by a person within the business with knowledge of the acts, events, conditions, opinions,.
Maintaining a Legally Sound Health Record Paper and Elect.docxcroysierkathey
Maintaining a Legally Sound Health Record:
Paper and Electronic
The health record is the legal business record for a healthcare organization. As such, it must be maintained in a
manner that follows applicable regulations, accreditation standards, professional practice standards, and legal
standards. The standards may vary based on practice setting, state statutes, and applicable case law. An attorney
should review policies related to legal documentation issues to ensure adherence to the most current standards and
case law.
HIM professionals should fully understand the principles of maintaining a legally sound health record and the potential
ramifications when the record’s legal integrity is questioned. This practice brief will review the legal documentation
guidelines for entries in and maintenance of the health record—both paper and electronic. Many of the guidelines that
originally applied to paper-based health records translate to documentation in electronic health records (EHRs). In
addition, new guidelines and functionalities have emerged specific to maintaining legally sound EHRs. It is of the
utmost importance to maintain EHRs in a manner that will support a facility’s business and legal processes, otherwise
duplicate paper processes will need to be maintained.
AHIMA convened an e-HIM® work group to re-evaluate and update the 2002 practice brief “Maintaining a
Legally Sound Health Record” to address the transition many organizations face in the migration from paper to
hybrid to fully electronic health records. Issues unique to EHRs are addressed specifically if they are different or
require expansion. Many organizations use a hybrid record (which includes both paper and electronic
documentation), scanning paper documents into an electronic document management system. Even though a scanned
document ends up in an electronic state, the documentation principles for paper-based records still apply. If there
are unique issues for scanned records, they are specified in this brief.
Authentication for Legal Admissibility
Generally, statements made outside the court by a party in a lawsuit are considered hearsay and not admissible as
evidence. Documentation in the health record is technically hearsay; however, Federal Rules of Evidence (803(6))
and the Uniform Business and Public Records Act adopted by most states allow exception to the hearsay rule for
records maintained in the regular course of business, including health records. All records must be identified and
authenticated prior to admissibility in court.
Four basic principles must be met for the health record to be authenticated or deemed admissible as evidence. The
record must have been:
� Documented in the normal course of business (following normal routines)
� Kept in the regular course of business
� Made at or near the time of the matter recorded
� Made by a person within the business with knowledge of the acts, events, conditions, opinions, ...
The Role of Fixed Asset Appraisals in Healthcare Valuations PYA, P.C.
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Business associate policy and procedure 10
1. Ophthalmic Associates of Fort Washington
Business Associate Policy and Procedure
Reference: Administrative safeguards standards section 164.308(b)(1)—Business
Associate Contract and other Arrangements
Issued: 01/01/2014
Effective Date: 01/01/2014
Policy Number: 10
Approved by: Tara Kresge
_____________________________________________________________________________
_
Policy
Ophthalmic Associates of Fort Washington will establish Business Associate Agreements to
ensure that organizations that 1) create, maintain, receive, or transmit electronic protected health
information (ePHI) for Ophthalmic Associates of Fort Washington or 2) provide legal, actuarial,
consulting, data aggregation, management, administrative, accreditation, or financial services for
Ophthalmic Associates of Fort Washington will appropriately safeguard this information.
Ophthalmic Associates of Fort Washington will update the Business Associate Agreements
implemented in accordance with the Privacy Rule to incorporate the requirements of the Security
Rule.
Procedures
Written Contract or Other Arrangement
The security officer will determine all organizations that are considered business associates.
Agreements with all business associates will be documented via a written contract. All business
associates will be required to implement “reasonable and appropriate” safeguards to protect ePHI
and to notify the practice if they become aware of a “security incident.” Business associates will
also be required to enter into similar agreements with subcontractors to whom they delegate a
function, activity, or service they have agreed to perform for Ophthalmic Associates of Fort
Washington that involves the creation, receipt, maintenance, or transmission of protected health
information.
Examples of business associates include:
• Billing companies
• Software vendors
• Transcription services
• Medical record storage companies
• Answering services
• Accountants
• Consultants
• Health information organizations