Tag C 330 COP: Periodic Evaluation s2

PIN CAH CMS Standards Review Conference Call Notes

Call: Feb 23, 2011

Tag C 306, Clinical Records, Completeness

“Promptly Completed”/delinquencies

MRMC: MR staff have a QA form they use to review records on a monthly basis

o When delinquent, they tag the record and write a note to the practitioner, then document when it was completed

o If delinquency continues, the MR Director writes a dated memo to the practitioner and a copy is placed in the practitioner’s credentials file o If delinquency continues after the dated memo, the delinquency is reported to the CEO for management

Dahl: the DON reviews records for completeness using a QA form

Tag C 307, Clinical Records: Signed, Dated, Timed

Current List of Authenticated Signatures

Barrett: when new medical staff are credentialed, they have the provider sign a Signature Authentication form along with other credentials papers

o Form goes to and is retained by HIM o HIM responsible for removing from list providers no longer on staff

Malta: does the list need to contain signature authentication forms for teleproviders, like teleradiologists

o Only if the provider signs a paper order/report, etc o If everything is done electronically, including electronic signature by the radiologist/provider, the HIT system verifies the electronic signature and the standard is met

See also notes from the Jan 2011 call

1 PIN CAH CMS Standards Review Conference Call Notes

Tag C 308, Clinical Records: Protection from Loss, Destruction and Unauthorized Use

Pioneer: received a deficiency on last survey because maintenance staff had access to the MR by a key given to them for emergency use

o To correct the deficiency: had to secure the emergency-use key and limit access to it to authorized individuals only; maintenance staff must now be accompanied by an authorized individual into MR when access by them is needed

CMMC: MR staff must be present in the area when housekeeping is present to clean

o Has only 1 “visit record” for each patient unless the patient is transferred to swing - ‘visit’ record includes ED, Obs, acute, ob, etc - their business office staff separate the charges as appropriate for the care delivery site

Protection from Loss/Destruction in an Emergency: flood, fire, wind storm, etc

Facilities will check to ensure that what to do to protect MR in an emergency/natural disaster is addressed in their emergency preparedness plans and/or MR policies/procedures. The policies should include how to prevent unauthorized use during the emergency. In general, this may be easier for facilities with electronic records.

Plentywood: has a procedure for drying out a MR when it has gotten wet

Non-emergency Protection from Unauthorized Use:

o Policy prohibiting removal from the facility o HIPAA policies o Records cannot be copied to discs and removed from facility for unauthorized uses o HR has policies concerning consequences of unauthorized staff accessing records

Policy granting the patient direct access to his/her record “unless it will have an adverse effect on the patient”:

Fallon: this is addressed in their Release of Patient Confidential Information policy. Four (4) patient conditions have been identified that might have an adverse effect on the patient if they or others had access to their record: o Victim of child abuse o Patient abuses alcohol and/or drugs o Patient has a psychiatric or behavioral/mental health disorder o Patient involved in criminal behavior

The record is flagged to warn all hospital staff, including HIM and RM, not to release information under any circumstances without express, written consent by the patient that it can be released to a specific individual/organization for a specific issue.

Others: the attending provider determines whether or not accessing the record might have an adverse effect on the patient, but there are no formal policies to address this.

Tag C 309, Clinical Records: Use and Removal

MRMC: by policy, the MR never leaves the CAH, not even to go across the parking lot to the clinic

Tag C 310, Clinical Records: Patient’s Consent for Release

The group discussed whether or not the notes from consulting providers or prior providers are copied and sent when an authorized consent to receive a copy of a record is received from another healthcare organization. The following regulations, received from Barrett HHC, provide some guidance on that issue:

MCA 50-16-803. Definitions. As used in this part, unless the context indicates otherwise, the following definitions apply: (3) "Health care information" means any information, whether oral or recorded in any form or medium, that: (a) is created or received by a health care provider; (b) relates to the past, present, or future physical or mental health or condition of an individual or to the past, present, or future payment for the provision of health care to the individual; and (c) identifies or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

23.1 The Designated Record Set (HIPAA)

The key to determining if something is part of the designated record set is whether it is used, in whole or in part, to make decisions about the individual. Peer review and quality assurance data typically would be not part of the designated record set because such data is used to evaluate the provider, not to make decisions about the individual. The following are part of the designated record set:

Medical records

Claims adjudication information

Patient account information

Advance Directives

 PHI received from another provider. (Note: other providers’ records contained in the patient’s file are part of the designated record set unless they were not used at all to make decisions about the individual. For instance, records received from another provider by mistake and not reviewed by the necessary provider would not be part of the designated record set.)

Diagnostic Films

Electrocardiogram Tracings

Release of PHI after the Patient Expires

See MCA 50-16-522: after a patient dies, the record can be released to a living relative, but only to the first eligible recipient, in this order: spouse, then children

Tag C 311, Clinical Records: Retention

No questions/issues

Next Call: Wed, March 23, 2:00 pm beginning with tag C 320 Surgical Services, through C 322 Anesthesia Services