Medical Record Management and HIPAA

Medical Record Management

• The objective is to have an effective and manageable filing system.
• Access to medical records should be limited to essential personnel.
• Essential personnel include doctors and medical assistants.
• Front desk staff, drug representatives, and cleaning crews should not have access.
• Restricting access helps comply with HIPAA regulations.

Patient File Categorization

• Active files are for patients seen regularly, such as every three months for chronic conditions.
• Inactive files are for patients who visit infrequently, such as once a year.
• Closed files are for patients no longer using the clinic for various reasons.
• Reasons for file closure include patient relocation, death, or dismissal from the clinic.
• Clinics can "fire" patients for aggressive or inappropriate behavior.

Records Retention

• Determine how long to keep records before disposal.
• Financial records must be kept for 10 years as a federal requirement.
• Medical records may also be needed to confirm services for 10 years.
• HIPAA has specific retention requirements that vary by state and insurance company.
• Records must be destroyed entirely after the retention period.
• Storage facilities can be used to store records beyond the retention period.
• Clinics must continuously assess their filing system for efficiency.
• Restricting record access is crucial for privacy and HIPAA compliance.
• Doctors, physicians, and FDMA should have access to medical records.
• Front desk staff, drug representatives, and cleaning crews should not have access.
• Only essential personnel should have access

Reasons for Firing Patients

• Aggressive behavior
• Continuous violent or angry actions

Duration

• Financial records must be kept for 10 years per the Federal False Claims Act.
• Specific retention periods that align with federal standards are required by HIPAA.

Storage

• Storage facilities can be used to manage space.
• Sensitive information should not be left in unsecured locations.
• Records must be shredded after the retention period to prevent information breaches.
• Continuous monitoring and updating of the filing system are essential.
• Access to medical records should be strictly controlled.
• Precise categorization of files helps manage active, inactive, and closed files.
• Retention policies must comply with federal and HIPAA guidelines.

Telephone Techniques

• Professional telephone communication in a medical office setting is key
• Essential office equipment, effective communication strategies, making a good impression, handling different call types, & HIPAA guidelines are included
• Equipment typically found in a medical office:
  • Multi-line Phones: Allow multiple calls simultaneously
  • Call Routing: Directs calls to appropriate personnel
  • Voicemail and Answering Machines: For after-hours messages
  • Office Cell Phones: Used for specific work-related communications
  • Answering Services: Automatically direct calls when staff is unavailable
  • Pages: Less commonly used, but still relevant
• Considerations for patients who are deaf or hard of hearing, consider:
  • Telecommunication Devices such as iPads with interpreters
  • In-person Interpreters to assist during appointments
  • Always communicate directly with the patient, not the interpreter
• The 5 C's of Effective Communication:
  • Completeness: Ensure both parties fully understand the message
  • Clarity: Make the message clear and understandable
  • Conciseness: Be brief and to the point
  • Courtesy: Be polite and respectful
  • Cohesiveness: Ensure the message is organized logically
• HIPAA guidelines:
  • Maintain patient confidentiality
  • Avoid discussing sensitive information in public areas
  • Be mindful of eavesdropping prevention
• Customer Service Voice:
  • Pronunciation: Correctly pronounce words
  • Enunciation: Clearly articulate each letter in a word
  • Tone: Use a friendly and professional tone
• Making a Good Impression:
  • Be Courteous: Display politeness and respect
  • Undivided Attention: Focus solely on the caller
  • Properly Handle Holds, Always ask before placing someone on hold
  • Remembering Names: Use general greetings if forgotten
  • Communicate with Empathy: Show understanding and care
• Ending Conversations:
  • Conclude calls with talkative patients by emphasizing future interactions
  • Escalate angry or abusive callers issues to a higher authority
• Types of Calls:
  • Patient Calls: Appointments, billing, test results, and medication inquiries
  • Attorney Calls: Directed to the clinic manager
  • Other Physicians and Salespeople: Handled based on the nature of the inquiry
• Telephone techniques increase communication efficiency, maintain patient confidentiality and improve patient care better

Managing Incoming Calls

• Management involves key steps and considerations, confirm patient's information
• If the doctor. is unavailable, collect a callback number and message
• Politely decline unsolicited sales calls, even if they offer incentives
• Screen urgent calls and triage. Medical assistants handle routine calls
• Utilize a guide to ask specific questions and determine the need for an appointment or emergency care

Accurate Phone Messaging

• Avoid multitasking while taking messages and log using electronic health records (EHR)
• Ensure correct spelling; avoid personal abbreviations to prevent misinterpretation
• Maintain patient confidentiality by shredding notes after transferring information to the computer

Telehealth and Remote Monitoring

• Telehealth appointments: Ensure patients are in private for HIPAA
• Remote Patient Monitoring: Ask patients to use home equipment like blood pressure monitors and report readings

Scheduling Management

• Computerized Scheduling: Block vacations & sick days. Identify problem patients using flags in EHR. Run compliance reports
• Color Coding: Use color codes for appointments to identify provider availability quickly

Systems for Scheduling

• New vs. Established Patients: New patients need more time
• Double Booking: Only double book with approval

Special Scheduling Situations

• Emergencies: Schedule manageable emergencies; refer severe conditions to the ER
• Referrals and Fasting patients should: Ensure insurance approval or schedule fasting patient early
• Late Arrivals and Walk-ins: Adhere to a late policy and reschedule
• Outpatient Procedures: Facilitate urgent imaging requests using backline numbers

Scheduling Outpatient Procedures

• Scheduled mainly if same-day imaging is required patients call with the results
• Maintaining the practitioner's schedule prevents from overwhelming or underutilizing
• Overbooking leads to practitioner burnout. Example: Seeing 50 patients when scheduled for 15
• Underbooking causes anxiety Ex: Seeing only 3 patient when scheduled for 15
• Office manager should work closely with the front desk to manage scheduling to prevent overbooking
• Clinic Managers handle travel for work purposes like conferences and meetings that involves scheduling one-on-one meetings

General Communication Guidelines

• Always maintain the patient's privacy, be conscious of volume to ensure confidentiality and be polite
• Professional Persona: User customer service voice including correct pronunciation, enunciation, and tone

Key Communication Techniques

• Pronunciation and Enunciation: Ensure words are pronounced correctly; all letters are articulated
• Tone of Voice: A friendly and professional tone improves interaction
• Smiling: Patients can "hear" a smile which enhances their experience

Handling Phone Calls

• Undivided attention avoids missing crucial information
• Remember patient names for rapport
• Definition of Empathy: Relating to patients with active listening and understanding

Ending Conversations

• Politely end calls by setting expectations for future interactions for talkative patients
• Acknowledge frustration and escalate if necessary for angry patients

Types of Calls

• Patient Calls: Scheduling, billing questions, and medication instructions
• Attorney Calls: Direct to the clinic manager
• Physician and salespeople calls should confirm patient information and transfer/directed to the clinic manager

Managing Incoming Calls

• Assess urgency when screening calls and directing appropriately
• Triage is typically handled by registered nurses

Accurate Phone Messaging

• Focus avoid multitasking
• Electronic health records (EHR) log system document messages
• Correct Spelling and Abbreviations prevent misunderstanding
• Handle all hand written notes and messaging with confidentiality

Telehealth Considerations

• Ensure the patient is in a private setting maintaining privacy
• Telehealth presents unique challenges; patients being in public spaces

Remember:

• Effective communication involves being clear, professional, & empathetic to provide the best patient care

Remote Patient Monitoring

• Patients are often asked to check their blood pressure with reliance on self-reporting data
• Some find managing clinic is daunting because "Doctors be crazy"

Schedule Management

• Computerized scheduling: EHR allows for vacation & prevents patient scheduling conflicts
• Viagra refill necessitates an appointments if the patient hasn't been seen in over a year
• Identifying Problem Patients using excessive no-shows or specified provider preferences
• Easy identification of appointment types using color coding

Online Scheduling

• MyChart enables patients to schedule appointments online that reduces phone traffic

Matrix and Appointment Types

• Vary from 15-60 min based on need for different appointments
• Organizational Appointment Types should be considered: New vs. established appointments
• Appointment Confirmations: MethodsText messages, emails, other automated calls

Special Situations to Consider

• Emergencies, referrals and insurance, specialty clinics
• Note whether cases are severe enough that they need to go to a hospital

Outpatient Procedures

• Schedule consultations, lab tests, imaging studies, etc

Practitioner Schedule

• Avoid overbooking and under booking, especially with new and specialized cases, and whether an inpatient procedure needs to be scheduled

Vital Signs

• Essential indicators that determine whether someone is healthy, and include heart rate (60-100 BPM for adults), blood pressure (ideally 120/80 mmHg using a sphygmomanometer), respirations (12-20 respirations per minute for adults), temperature, and O2 levels

Filing

• Requires standard equipment for filing and storing paper records, and considering security and safety measures.
• Equipment: filing shelves filing cabinets, binders, etc.
• HIPAA requires safeguards

Systems for Filing

• Sequential Order, Alphabetic Filing System, Chronological Filing, Numeric Filing System- Color-coding in both alphabetic and numeric systems
• Always Inspect when filing
• Check cross-reference files daily

Storage

• Options: use facilities for old records to save space

Telecom

• Crucial equipment multi-line phones, call routing, voicemail, answering machines, answering services, cellular phones, pages, etc
• When communicating with the deaf always use special tips and equipment

Always remember:

• 5 Cs
• telephone etiquette
• policies and procedures
• and to be HIPAA compliant!

Appointment Book

• Is Key to Continuity of Patient Care for maintaining schedules and generating reports