...The patient health record contains important information regarding clinical quality and care. The health record is also undergoing a radical evolution as more imaging becomes available and digital record keeping becomes the norm. The HIM professional needs to have a clear understanding of how to manage increasingly complex sources of health information. In this paper, we will discuss how the HIM professional should manage the use of paper forms in a hybrid environment in order to maintain the integrity of the health record. We will also compare the strengths and weaknesses of using hybrid records and discuss legal issues that may arise when using hybrid records. Additionally, we will evaluate the “Willow Bend Record Policy” to determine if it protects health information for record storage and destruction of paper and electronic health records based on Kansas state regulations, Medicare Conditions of Participation, and Health Insurance Portability and Accountability Act (HIPAA). The term hybrid health record is used in today’s healthcare environment to describe a format that has both paper based and electronic information. Given that this type of health record is complex in content, it comes with additional requirements in regard to management. This is particularly true when comes to managing patient information into a concise, presentable formation. As HIM professionals, we should also be seeking ways to improve access to information and balancing that access with security....
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...Internationally security techniques and standards, such as ISO 17799, establish guidelines that organizations must implement in order to maintain information security. Information must be protected from those without a readily need to know to perform organizational business functions. Unauthorized access to information can have a detrimental impact on an organization from a legal and operating perspective. One of the primary preventive controls that provide an organization with many operational benefits is continuous log management policies. In addition to helping solve network security related issues, logs can be extremely beneficial in identifying unauthorized access and behaviors. Security logs assist in identifying policy violators, fraudulent behavior, real time operational problems, and provide necessary data to perform auditing, transaction back tracking and forensic analysis. In addition to the many benefits of having policies in place for continuous log analysis, standards and regulations have increased business awareness of the requirements for archiving and reviewing system logs as part of daily continuity. Some of the influential regulations that reference log management and other information security task include the following. • Federal Information Security Management Act of 2002 (FISMA) requires entities to ensure the development and execution of organizational processes and internal controls designed to secure information systems. Health Insurance Portability and Accountability...
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...RCAP 2008 Rationales and Recommendations for Compliance for MLS, DMS, MLT, HT/HTL, CG, and PathA programs (*compatible with merged Guide to Accreditation) (version: October 2011) [pic] |Standard 1 | |Standard 1 | | |1-1 |The [sponsoring institution/affiliate(s)] is (are) not accredited by a recognized |1-1 |Submit documentation that the [sponsoring institution] [affiliate(s)] is (are) | | |agency. | |currently accredited by a recognized agency. | |1-2 |There is (are) no signed agreement(s) with [affiliate(s)] |1-2 |Submit a copy of a signed and dated current agreement with _______________________. | | | | | | |1A-1 |The agreement does not address the reason for the agreement |1A-1 |Submit (an) (the) agreement(s) which address(es)...
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...DEVELOPING A FATIGUE MANAGEMENT PLAN FOR COMMERCIAL VEHICLE DRIVERS AND OPERATORS Developing a Fatigue Management Plan for Commercial Vehicle Drivers and Operators ● 2 / 20 INTRODUCTION ................................................................................................................................................ 4 COMMERCIAL VEHICLE DRIVER FATIGUE IS A MAJOR SAFETY PROBLEM .............................................................. 4 A DRIVER FATIGUE MANAGEMENT PLAN WILL HELP EMPLOYERS MEET THEIR DUTY OF CARE ............................. 4 OPERATING STANDARDS FOR WORK AND REST .................................................................................. 5 THE OPERATING STANDARDS IN THE REGULATIONS ARE USED TO ESTABLISH A SAFE SYSTEM OF WORK ............. 5 OPERATING STANDARDS FOR WORK AND REST IN ROAD TRANSPORT ................................................................... 5 DRIVING WITHOUT A RELIEF DRIVER ................................................................................................................... 5 DRIVING WITH A RELIEF DRIVER .......................................................................................................................... 5 A DRIVER FATIGUE MANAGEMENT PLAN............................................................................................... 6 MANAGING COMMERCIAL VEHICLE DRIVER FATIGUE REQUIRES EFFECTIVE POLICIES & PROCEDURES ................ 6 BASIC PRINCIPLES TO INCLUDE...
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...dishonest practices the government has set up standards of reporting income and expenses. The function of the generally accepted accounting principle is that all companies report revenue using the same methods. Using the four elements of financial management, planning, controlling, organizing, and decision making, businesses can be successful. Using ethical standards of honesty, an organization can expect to remain in business. Generally accepted accounting principles (GAAP) is the standard that determines how accountants conduct reports (Kennan, 2014). The function of the GAAP is to ensure that companies have the same methods of reporting financial information. The GAAP applies to all financial statements issued to the public for investors to understand how the company is reporting income and expenses (Kennan, 2014). The financial accounting standard boards (FASB) created the GAAP that define the ethical standard practices of companies (Reeves, 2014). Maintaining high ethical standards accountants must maintain confidentiality when reporting financial reports. Accountants must enter accurate data, and validate amounts entered into financial transactions. Accountants must have backup documents to support any correction made. Use internal controls in each department to ensure competency of the accountant. Accounting clerks should be separated from the payable clerks and accounts receivable clerks. Neither can access the other’s information and only one accountant signs checks and...
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...Nurses in Use of Electronic Documentation The field of health information technology for nursing is rapidly growing. Advancements in electronic documentation for health care, such as the electronic medical record (EMR), can be an overwhelming addition to the workload of nurses. There is resistance by nurses in use of electronic documentation (Sharifian, Askarian, Nematolahi, & Farhadi, 2014). It is this writer’s opinion that nurses are under informed regarding the rationale for changes taking place in documentation and the implications. The purpose of this paper is to provide nurses with the basics of the Federal regulations outlined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) that require electronic documentation to be compliant and receive reimbursement. It also reviews how data are collected to determine the reimbursement for care (meaningful-use) and its role in evidence-based practice (Wright, Feblowitz, Samal, McCoy, & Sittig, 2014). Included is a review of the negative impact resistance generates on health organization reimbursement and the relevance it has on nurse staffing, jobs, wages, and satisfaction, along with, evidence reinforcing the training and support of nurses as a means to promote proper use of electronic documentation and increase user satisfaction. Federal Laws and Requirements for Compliance Health care agencies in the United...
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...meet the minimum standards in order to operate, such as sufficient staffing, personnel employed to provide services, the quality of equipment, buildings, and supplies, and services provided, including health records. (LaTour, 2013) Medicare has developed Conditions of Participation and Conditions for Coverage, which identifies specific criteria that must be met in order to receive reimbursement from Medicare. Medicare implements these guidelines in order to set a standard for improving quality of care and maintaining the health and safety of its beneficiaries. (CMS, 2013) State agencies conduct annual surveys of licensed facilties to ensure they are operating at or above the minimum standards set forth by the sate and CMS. It is imperative for licensed healthcare agencies to meet the guidelines of the Conditions of Participation in order to receive reimbursement, if they do not meet the minimum standards they could be unable to participate with Medicare, thus losing patients and revenue. Physician Quality Reporting System requires healthcare providers and hospitals to meet clinical quality standards and record them. Physician Quality Reporting System is a program implemented by Medicare that uses incentive payments and incentive adjustments in order to promote reporting of quality information from its eligible participants. In order to receive incentive payments, the eligible provider must meet the minimum standard criteria for reporting quality information. Beginning in 2015...
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...to maintain health information exchange this is a barrier to EHR implementation and health information exchange. Although there are some businesses and many family-owned farms they do not heavily use technology and often do not offer health insurance benefits to their employees. The community also has a significant population of undocumented immigrants that work on the farms and in oil fields. The Smiles critical access hospitals is a small free standing clinic with under 25 beds. * Smiles clinic has on staff one IT/telephony expert, two coders and one billing administrative clerks. * IT/Telephony expert * Coding experts: * Submit claims in accordance with government regulations and private payer policies, follow-up on claim statuses, resolution of claim denials, appeals submission, posting of payments and adjustments, and collections management. * Coding professionals are expected to support the importance of accurate, complete, and consistent coding practices for the production of quality healthcare data. * Coding professionals in all healthcare settings should adhere to the ICD-9-CM (International Classification of Diseases, 9th revision, Clinical Modification) coding conventions, official coding guidelines approved by the Cooperating Parties,* the CPT (Current Procedural Terminology) rules established by the American Medical Association, and any other official coding rules and guidelines established for use with mandated standard code sets....
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...throughout this policy shall include all steps described in the Human Resource policy manual and faculty policies and regulations including, without limitation, termination and tenure revocation). This Plan provides for oversight by a Compliance Program Medical Director and Compliance Officer. Although the intent is to encourage compliance through a centralized audit system, it remains the responsibility of each individual involved with the billing process, from physicians and other providers to clerical staff, to comply with the law. The purpose of this Plan is to ensure that clinical services are adequately documented and that properly coded bills are submitted only for documented services. This Plan is to be read in conjunction with and is an integral part of the University of Rochester Medical Center Compliance Plan, which is set forth in a separate document. In addition, it is anticipated that individual departments of the University will create specialty-specific billing compliance plans, which will be subject to review by the Compliance Program Medical Director and Compliance Officer. The University acknowledges that this plan is only the beginning of its efforts to institute a program and oversee compliance with applicable laws and regulations. The key to success, in which all employees play a part, is ongoing adherence to the highest standards of conduct and the development of a workable system in which employees are educated about compliance and participate in...
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...updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited. In 2010, the policy addressing terminology and abbreviations was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.0 by Joint Commission. The hospital administration or HIM administration should have a committee to ensure the terminology and abbreviations are updated and distributed to all clinical areas, are posted within the electronic record system, and performed within specific time frames. The policy for addressing backup of electronic information systems can be found in Standard IM.01.01.03. The policy for managing interruptions to information processes is located within this Standard. This standard should be in the HIM department’s policy as well as IT department. The Medical Records Manager and IT Manager should maintain communication as to backups, updates, and scheduled downtime. IT will ensure all hospital employees’ awareness of any downtime for maintaining equipment as necessary. The release of information policy would be accessed in the Standard IM.02.01.03. This policy addresses...
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...6 May 2011 Heart-Health Insurance Information Security Policy Proposal By Thomas Groshong A review of the current New Users and Password Requirements policies and the proposed changes to these policies with justifications are listed below. Current Policies: New Users “New Users are assigned access based on the content of an access request. The submitter must sign the request and indicate which systems the new user will need access to and what level of access will be needed. A manager’s approval is required to grant administrator level access.” Current Policies: Password Requirements “Passwords must be at least eight characters long and contain a combination of upper- and lowercase letters. Shared passwords are not permitted on any system that contains patient information. When resetting a password, users cannot reuse any of the previous six passwords that were used. Users entering an incorrect password more than three times will be locked out for at least 15 minutes before the password can be reset.” A: Revised Policies: New Users “New Users are assigned appropriated access based on their role within the organization and their need to access specific data and/or data stores. The user and supervisor must submit a signed request and indicate which systems (Roles) the new user will need access to and what level of access will be required. To grant administrator level access an additional signature from a manager is required. New Users are required training on workforce awareness...
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...6 May 2011 Heart-Health Insurance Information Security Policy Proposal A review of the current New Users and Password Requirements policies and the proposed changes to these policies with justifications are listed below. Current Policies: New Users “New Users are assigned access based on the content of an access request. The submitter must sign the request and indicate which systems the new user will need access to and what level of access will be needed. A manager’s approval is required to grant administrator level access.” Current Policies: Password Requirements “Passwords must be at least eight characters long and contain a combination of upper- and lowercase letters. Shared passwords are not permitted on any system that contains patient information. When resetting a password, users cannot reuse any of the previous six passwords that were used. Users entering an incorrect password more than three times will be locked out for at least 15 minutes before the password can be reset.” A: Revised Policies: New Users “New Users are assigned appropriated access based on their role within the organization and their need to access specific data and/or data stores. The user and supervisor must submit a signed request and indicate which systems (Roles) the new user will need access to and what level of access will be required. To grant administrator level access an additional signature from a manager is required. New Users are required training on workforce awareness, password management...
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...#1…Public health IN THE United States, primary care remains a medical model. This is in contrast to much of the world, where the 1978 Declaration of Alma-At a which recognized that attaining health for all also requires interaction from social and economic sectors - is considered standard. Today, there is much buzz about patient-centered medical homes, a concept that promises to transform the practice of American medicine. There is much to praise about this most recent iteration of the medical home. But the missing ingrethent in all these definitions and models remains public health. A population focus that addresses the social determinants of health is an essential component of primary health care. In the United States, such a comprehensive approach has been labeled community-oriented primary care. This model is built firmly on the Alma-Ata principles and incorporates a public health approach to health services. Community-oriented primary care organizes the delivery of health services, around a population, not simply a collection of individuals. It identifies a population - most frequently a geographically defined community - and uses epidemiology and interventions to improve community and individual health and well-being. In this model, both individual patients and the community are the foci of the delivery of health services. Primary health care stands at the intersection of personal and population health services. It requires integrating medical models of primary care...
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...The Health Information Technology for Economic and Clinical Health Act, better known as HITECH, is part of the American Recovery and Reinvestment Act of 2009. ARRA contains incentives related to health care information technology in general and The HIPAA Privacy Rule gives you rights over your own health information, regardless of its form. Whether your record is in paper or electronic form, you have the right to your records. HIPPA contains specific incentives designed to accelerate the adoption of HER systems among providers. The HIPPA act contains 5 different sections. Tite 1, the health insurance reform. Title I protect health insurance coverage for individuals who lose or change jobs. Title 2 is known as...
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...elements of a conformity assessment system are: * A quality management system (QMS) * A postmarket surveillance system (PMS) * Summary technical documentation * A Declaration of Conformity * Registration of manufacturers and their IVD medical devices with the regulatory authority. **Conformity: A declaration by the IVDD manufacturer that the device is safe and performs as intended. Ref: Regulatory Affairs Professional Society; Fundamentals of International Regulatory Affairs, Second edition Conclusion: Every country has variations in the way IVDD is being regulated. With different classifications, regulatory body etc. I would recommend you to decide on a few specific countries which would be the potential market for your device (within Latin America) and then you will be able to narrow your research on its regulatory pathway. There are some common elements that comprise the approval process and required submission documentation for medical device approval in many Latin American countries. These include: * A Technical File or Report similar to a CE Technical File (technical description, device safety test results, biocompatibility data, labeling, etc). The required amount and type of information varies depending on the country. * A Certificate of Free Sale (CFS) issued by the public health authority in the country of origin, whichdemonstrates that the device is cleared for sale in the US, Europe, or another country which has an established trade...
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