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Overview of Documentation. KNR 279. DOCUMENTATION. What is documentation? A permanent legal record that is standardized and systematic Permanent Legal Standardized. Physicians Psychiatrists Nurses Allied Health Professionals Hospital Committees CQI Administrators. Internal Auditors

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documentation
DOCUMENTATION
  • What is documentation?
    • A permanent legal record that is standardized and systematic
      • Permanent
      • Legal
      • Standardized
who reads what you write
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?
documentation1
DOCUMENTATION
  • Why do we document?
    • Assure quality services
    • Communicate with staff
    • Professional accountability
    • Provides information to be evaluated
    • Provides information to determine efficacy
    • Requirement
documentation2
DOCUMENTATION
  • Types of documentation
    • Program Documentation
    • Client Documentation
program documentation
PROGRAM DOCUMENTATION
  • Written plan of operation
  • Comprehensive program
  • Protocols
  • Quality improvement documents
  • Program evaluation
  • Policy & procedure manuals
  • Staff manuals
client documentation
CLIENT DOCUMENTATION
  • Assessments
  • Treatment plans
  • Progress notes
  • Discharge notes
  • Referral summaries
  • Participation records
  • Other agency records
documentation3
DOCUMENTATION
  • Flow pattern for client documentation
    • Assessment
    • Assessment summary
    • Goals & objectives
    • Treatment plan
    • Progress notes
    • Discharge notes
purpose of record documentation
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
documentation4
DOCUMENTATION
  • How would you define good documentation?
    • Accurate
    • Good writing skills
    • Black / blue ink
    • Legible
    • Honest, factual & timely
    • Signed with credentials
    • Confidential
what is confidentiality
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
confidentiality things to avoid
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
confidentiality
CONFIDENTIALITY
  • Talking about work at parties, bar, etc.
  • Speaking with client in front of other clients
  • Identifying clients outside of the hospital
hipaa
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
hipaa1
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
patient protections
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
patient protections1
Patient Protections
  • Must have written privacy procedure including
    • Staff that have access
    • How information can be used
  • Must have employee training and privacy officer
individually identifiable health information
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
individually identifiable health information1
Individually Identifiable Health Information
  • All medical records including but not limited to doctors’ notes & orders, x-rays, lab reports, nurses’ notes, etc.
use disclosure
Use & Disclosure
  • Treatment
  • Payment
  • CQI
  • Research
  • Education
  • Law suits & other required disclosures
    • (Public health, abuse, worker’s comp.)
civil criminal penalties
Civil & Criminal Penalties
  • Monetary
    • Up to $100 per violation
    • Up to $25,000 per year
    • For each requirement or prohibition violated
civil criminal penalties1
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.