Radiology & Health Records: Key Questions

• Health Information Management involves maintaining all patient care information by all healthcare providers
• Health records consolidate patient care information into a single record
• Effective communication is promoted with records
• Continuity of care is ensured with health information management

Health Information Department Functions

• Supporting ongoing patient care
• Supporting administrative processes
• Records maintenance for patient billing and accounting
• Supporting medical education programs
• Supporting health services research
• Maintaining records for utilization, risk, and quality management
• Ensuring patient privacy and security
• Ensuring legal compliance
• Performing services related to patient records

HIPAA and Patient Access

• The Health Insurance Portability and Accountability Act of 1996 ensures patient access to personal health information
• 21st Century Cures Act is mandatory for health systems to provide patients with notes, reports, images, etc. via patient portals
• Patient portals facilitate patient involvement in healthcare
• Patient portals provide secure online access with convenient 24-hour availability to personal health data and medical records
• HIPAA is a federal act designed to protect health information privacy, ensure timely access, and secure electronic health records (EHR)

Health Information Systems

• Health information systems (HIS) manage healthcare data
• HIS allows for protected health information(PHI) sharing in the healthcare industry
• Radiology information system (RIS) is very vital to the information provided by HIS
• RIS manages imaging orders, scheduling, and billing and also supports patient management, tracking, and reporting
• A picture archiving and communication system (PACS) communicated with RIS
• PACS comprises a networked group of computers, servers, and archives to manage digital images
• Cloud-based PACS system helps to meets requirements for medical imaging modalities

The Joint Commission (TJC)

• The Joint Commission (TJC) accredits and certifies healthcare organizations in the US
• TJC establishes standards for health record maintenance and documentation

Medical Record Essentials

• According to TJC, a medical record needs sufficient information to identify the patient, support the diagnosis, and justify the treatment
• A medical record must document the treatment results and ensure care continuity
• According to Medicare, a medical record must justify admission and hospitalization, support diagnosis, and detail patient progress and response to services
• All departments involved in patient care must document that care in the health record
• Radiologists and radiographers should chart in the patient's record when diagnostic or therapeutic radiologic services are provided

AI Terminology

• Machine Learning: Algorithms trained on data to make predictions without explicit programming
• Neural Networks: Computational models inspired by the human brain, are used for pattern recognition
• Deep Learning: A subset of machine learning utilizing neural networks with many layers
• Natural Language Processing (NLP): Enables machines to understand and respond to human language

AI in Healthcare

• Al applications include diagnostic tools for early disease detection, personalized treatment plans, and accelerating the process of drug discovery
• AI is enhanced for use in X-rays, CT scans, and MRIs using image segmentation, classification, and reconstruction
• AI models improve diagnostic accuracy and faster image processing

The Importance of Data

• Data is the backbone of Al development
• Structured Data: Databases (e.g., tables)
• Unstructured data includes text and images
• High-quality, diverse data improves accuracy and reliability

AI Regulation

• Ethical AI means bias in algorithms is reduced with ensuring fairness and transparency
• It involves data privacy with protecting patient information and accountability with frameworks for Al-driven errors

Inpatient Record Standards

• Patient identification data
• Medical history of the patient, including chief complaint, present illness or injury, family and social histories
• Diagnostic and therapeutic orders
• Relevant physical exam report
• Clinical observations with therapy results
• Diagnostic and therapeutic tests and procedures reports, with results
• Evidence of informed concent when needed
• Conclusions at the end of hospitalization

Informed Consent

• Informed Consent implies that the patient has been informed of the procedure or operation to be performed, the risks involved, and the possible consequences
• Treatment Authorization: General permission from hospital for treatment or allowing treatments in the patient's best interest
• Treatment Authorization covers general diagnostic procedures and medical treatment with routine hospital services

Radiology Records

• Radiology orders or requests for imaging services
• Patient demographic information in health records that are used in radiology
• Specific procedures being requested
• Identification of the physician ordering the procedure
• The radiology heath records must have authentication
• Description of radiograph with implications for patients
• Date and time with documentation of dose of x-ray
• Date and time with radioactive material administered
• Special reports evaluating treatment

Physician Orders and Patient Portals

• All treatment, procedures, and medicine requires a physician order
• Patients access to viewing their health information and medical records is achieved with use of a secured online website

Medical Record Information

Includes:

• Patient ID
• Demographics
• Medical history
• Admission conclusions and impressions
• Diagnostic and therapeutic orders
• Clinical observations
• Physical exam report
• Consultation reports
• Diagnostic and therapeutic reports
• Surgical and invasive procedures reports
• Donation and implant records
• Conclusions at the end of stay
• Discharge information given to patient and their family
• Final diagnoses
• Prognosis
• Discharge summary
• Postmortem results
• Psychological needs summary
• Treatment plan
• Informed consents
• Progress notes

Health Record Reimbursement

• International Classification of Diseases, 10th edition, Clinical Modification (ICD-10-CM)- Used for diagnostic coding
• Current Procedural Terminology, 4th edition – Used to code the procedure for outpatient encounters and other services
• Correct coding is critical to reimbursement and ensure organization financial viability

Rules for Records

• Records are legal documents
• Record data in either ink or digital
• Electronic Health Records need verifiable authorization for data recording
• Requisite documentation in the health record to show what happened to the patient is a must
• Radiographers may need to provide depositions or testimony on procedures
• Authors should correct errors by Single lining with "ERROR", their records should be correct
• Individuals should date and authenticate the entry

Legal Aspects

• The original record is never left in court
• Informing patients of exam results is the physician's responsibility
• Technologists should direct the patient to their physician
• HIPAA guides the confidentiality needs of health records

Recording Information

Do:

• Writing legibly and use ink if on paper
• Spell correctly and use standards writing abbreviations
• Document precisely and correctly
• Keep it precise and to the point
• Enter the date and time of data entry
• Record data accurately
• Keep data private
• Sign your name and title on each data report Don’t:
• Write in pencil if on paper
• Erase information from report of data entry
• Use abbreviations that aren't standard practice
• Keep blank space in document data
• Add notes or comments about a patient or colleague

Sentinel events

• Relate patient's incidents
• Classify as sentinel event
• Completed after event

Performance Improvement

• Performance Improvement is a process that monitors and evaluates care quality and services to patients in a healthcare facility
• It is known as Quality Assurance or Quality Assessment

Assessment of Quality

• Utilization
• Risk, infection
• Surgical case, medication usage
• HHealth record, blood usage,
• Radiation
• Pharmacy and Therapeutic
• Case, hospital and department committees

Ownership

• Facility and caregivers own the records
• Patients may see records or view reports unless prohibited by law or patient medical conditions

Release of Information

• Consents for data must be writing
• Consents show
• whom the report goes to
• extent of data report
• date of the release
• patient/representative signatures

Email and Fax

• All reports sent by email or fax shall be private
• Sender/receiver should communication during the event of email and fax

Maintenance

• Records films/digital in secure site
• copies of image reports maintained with images and patients data files and reports

Conclusion:

• HI management keys in hospital data reports
• Healthcare ensures financial stability
• Patient records protect care
• Health records keep data private

Explore essential questions about health records in patient care, identity management, and the role of coding in radiology. Understand the benefits of systems like RIS and the impact of AI on radiology workflows. Learn about authorizations for treatment and required documentation for imaging procedures.