Description
Gain a better understanding of medical records and the laws and requirements that go along with managing them.Many organizations that are required to maintain medical records for patients often do not understand how to define their medical record in a manner that adequately satisfies applicable legal requirements and manages potential risks and liabilities. Many organizations also do not understand how to deal with new issues that are arising from the proliferation of electronic medical records, physician portals, and networked electronic health information exchange. Finally, many organizations do not fully understand the answer to the question of who owns the medical record, and particularly with respect to how to respond to patients, health care providers and other third parties who demand the right to access copies of such records. This topic will help the persons responsible for medical record management to understand how to define their organization’s medical record, including recognizing which documents and information should be included, which ones should be considered for exclusion, and which ones might need to be flagged for special treatment in accordance with appropriate policies and procedures. The material will also cover the most important topics for consideration when reviewing your organization’s current policies and procedures governing medical records and recognize if and what updates are needed. This information is important for health care providers and organizations so that they can ensure compliance with federal and state law medical record requirements, HIPAA, and to manage the risks and liabilities that could arise from medical records which are inadequately defined or managed.
Date: 2019-11-14 Start Time: End Time:
Learning Objectives
Defining the Medical Record
• State Law (i.e., Licensing Requirements)
• Federal Law (i.e. Medicare)
• Joint Commission Accreditation
• Electronic Medical Records
• Legal Record Issues
• Third-Party Documents
• E-Mail
• Patient-Physician Portals
• Health Information Exchanges
Rights to the Medical Record
• Patients’ Rights
• HIPAA: Right to Access
• HIPAA: Right to Amendment
• HIPAA: Right to Accounting of Disclosures
• Designated Record Set
• Authorized Representatives
• Who Owns the Medical Record?
• Duties of the Creators
• Duties of Other Custodians (i.e., Business Associates)
• Does the Health Care Provider Have a Right to the Record?
• Does the Patient Have a Right to the Record?
• Does Any Other Third-Party Have a Right to the Record?
Retention Standards
• Federal and State Law
• Minors’ Records
• Compliance/Audit Considerations
• Litigation Considerations
Helen Oscislawski, Esq.-Attorneys at Oscislawski LLC, Brad M. Rostolsky, Esq. – Reed Smith LLP
