Mastering Medical Records

Medical Information and Records: HIPAA, Protected Health Information, and Torts

• HIPAA is a US legislation that provides data privacy and security provisions for safeguarding medical and health information.
• HIPAA covers protected health information in any medium while the HIPAA Security Rule covers electronic protected health information.
• Effective documentation is essential in medical recording and charting, and charts must never be allowed to leave the healthcare facility.
• Medical records can be in paper format, electronic format, or both, and usually have a brief at-a-glance card at the beginning of the chart that lists basic patient medical information.
• Diagnostic images, whether stored digitally or on film, are legally considered part of the medical record and belong to the institution in which they are made.
• Radiology practices work with four major software tools: PACS, RIS, CIS, and DICOM, which streamline work flow and facilitate collaboration between radiology professionals.
• Torts are legal wrongs that can be intentional or unintentional.
• Intentional misconduct torts include assault, battery, false imprisonment, invasion of privacy, libel, and slander.
• Unintentional misconduct torts include negligence, malpractice, gross negligence, contributory negligence, and corporate negligence.
• Any patient’s or visitor’s or staff’s fall, accident, or occurrence that results in injury or potential harm must be reported immediately to the department supervisor or radiologist or both by completing an Incident Report or Unusual Occurrence Form.
• Lawsuits can result in conflict, expense, professional embarrassment, and loss of public confidence, so it is essential to prevent malpractice and always adopt caution for both the patient care interest and in the avoidance of possible malpractice claims.
• The 7 Cs of Malpractice Prevention are: competence, compliance, charting, communication, confidentiality, courtesy, and caution.