Overview of Documentation

1. Overview of Documentation KNR 279

2. DOCUMENTATION • What is documentation? • A permanent legal record that is standardized and systematic • Permanent • Legal • Standardized

3. Physicians Psychiatrists Nurses Allied Health Professionals Hospital Committees CQI Administrators Internal Auditors Insurance Companies Medicare surveyors JCAHO surveyors Attorneys Judges Juries And the list goes on Who Reads What You Write?

4. DOCUMENTATION • Why do we document? • Assure quality services • Communicate with staff • Professional accountability • Provides information to be evaluated • Provides information to determine efficacy • Requirement

5. DOCUMENTATION • Types of documentation • Program Documentation • Client Documentation

6. PROGRAM DOCUMENTATION • Written plan of operation • Comprehensive program • Protocols • Quality improvement documents • Program evaluation • Policy & procedure manuals • Staff manuals

7. CLIENT DOCUMENTATION • Assessments • Treatment plans • Progress notes • Discharge notes • Referral summaries • Participation records • Other agency records

8. DOCUMENTATION • Flow pattern for client documentation • Assessment • Assessment summary • Goals & objectives • Treatment plan • Progress notes • Discharge notes

9. PURPOSE OF RECORD DOCUMENTATION • Benefit to patient, staff, physician • Communication tool for planning patient care • Utilization review • Reimbursement • Quality Assurance, research, program evaluation • Legal document, accountability

10. DOCUMENTATION • How would you define good documentation? • Accurate • Good writing skills • Black / blue ink • Legible • Honest, factual & timely • Signed with credentials • Confidential

11. What is Confidentiality? • Right to share privileged information with healthcare provider • Provider keeps the information confidential • Pt’s identity, condition, emotional state, financial state • Right to be free from unnecessary probes into personal affairs • burlingame

12. CONFIDENTIALITY: THINGS TO AVOID • Discussing patient/work situations with family and friends • Informal discussions with colleagues • Inappropriate conversational remarks to consumers, visitors or employees • Incoming phone call in nonconfidential settings

13. CONFIDENTIALITY • Talking about work at parties, bar, etc. • Speaking with client in front of other clients • Identifying clients outside of the hospital

14. HIPAA • Health Insurance Portability and Accountability Act of 1996 • Developed by U.S. Dept. of Health & Human Services (HHS) • National standards to protect the privacy of personal health information • 1st ever federal privacy standards • Took effect April 14,2003

15. HIPAA • Enforced by HHS Office for Civil Rights • Who? • Any healthcare professional authorized to enter information in medical records • All employees, staff, students, & other clinical personnel

16. Patient Protections • Access to medical records • Can inspect, get copies, request corrections • Notice of privacy • How intend to use personal information • Limits on use of personal medical info. • Prohibition of marketing

17. Patient Protections • Must have written privacy procedure including • Staff that have access • How information can be used • Must have employee training and privacy officer

18. Individually Identifiable Health Information • Demographic data (name, address, birth date, phone number, etc.) • Past, present, or future physical or mental health or condition • Provision of health care to person • Past, present, or future payment • THAT identifies the person, or for which there is a reasonable basis to believe it can be used to identify the person

19. Individually Identifiable Health Information • All medical records including but not limited to doctors’ notes & orders, x-rays, lab reports, nurses’ notes, etc.

20. Use & Disclosure • Treatment • Payment • CQI • Research • Education • Law suits & other required disclosures • (Public health, abuse, worker’s comp.)

21. Civil & Criminal Penalties • Monetary • Up to $100 per violation • Up to $25,000 per year • For each requirement or prohibition violated

22. Civil & Criminal Penalties • Criminal • Up to $50,000 & 1 year in prison • Up to $250,00 & 10 years in prison • IF offenses committed with intent to sell, transfer, or use protected health information for commercial advantage, personal gain, or malicious harm.