Description
Understand your legal liability when it comes to computerized medical records, electronic health record systems, and EHR implementation.This course will discuss the appropriate uses and disclosure of electronic medical records, the risks involved with incomplete records, compliance with statutes and regulations relating to medical records, and data security. You will learn about how electronic medical records are used, the unique risks involved with electronic medical records, and how to best utilize medical records in a legal proceeding or investigation.
Date: 2023-03-16 Start Time: End Time:
Learning Objectives
Definition of Medical Record
• Legal Health Record
• Patient Identifiable Source Data
• Administrative Data
• Derived Health Information and Data
Purposes of Medical Record
• Depicts Patients Health History
• Facilitates Diagnosis, Management, and Treatment
• Provides Communication Among Healthcare Team
• Means to Obtain Reimbursement
• Promotes QA/Facilitates Peer Review
• Provides Compliance With Licensing and Accreditation Standards
• Provides Best Evidence in Malpractice Suit
• Facilitates Research and Education
• Consequences of Incomplete Record
Benefits of Good Recordkeeping/Charting
• Documentation Purposes
• Medical Records Equivalent to Testimony
• Guidelines for Good Documentation
• Avoiding Problems in Documentation
• Other Records
Unique Features and Benefits of Electronic Medical Records
• Dated and Timed
• Data Available in Real Time
• Integrated With Other Records
• Tabbing and Focused Charting
• Standardization of Terms
• Auto-Repopulation
• Avoid Inadvertent Deletion or Copying Problems
• Prevents Chart Manipulation
• Error Avoidance
• Alarms for Contraindications
• Remote Access
• Backup and Storage
• Consistent Coding
• Assists With Audits, Improper Billing, and False Claims Investigations
• Better Medication Management
Risks Unique to Electronic Medical Records
• Cutting and Pasting
• Mousespasms
• Brevity
• Typing Fatigue
• Alert Fatigue
• Access Restrictions and Differences
• Printing Differences
• Creating Higher Standard of Care
• Default Dangers
• Data Destruction
• Inappropriate Corrections
• Unauthorized Access
• Inaccurate Data Entry
• Breach of Confidentiality
Health Information Privacy and Data Security
• Health Insurance Portability and Accountability Act (HIPAA)
• HITECH Act
• Protected Health Information
• Covered Entities
• Business Associates
• Privacy Rule
• Security Rule
• Breach Notification Rule
• Administrative Safeguards
• Physical Safeguards
• Technical Safeguards
• Disclosures
• Accounting of Disclosures
• Enforcement
AHIMA ,CLE (Please check the Detailed Credit Information page for states that have already been approved) ,Additional credit may be available upon request. Contact Lorman at 866-352-9540 for further information.
Troy R. Rackham-Spencer Fane LLP
