Health Information and Administrative Policy Updates

Presented by Lizeth Flores, RHIT Anderson Health Information Systems Inc. 714-558-3887Office@ahis.net

Policy Updates

Committees – SB 158 Inclusion of Safety Committee requirements Must meet at least yearly Can be part of QA/CQI Committee Must have separate minutes

SB 158 – continued…

Administrative update includes a checklist to assist in identification of related safety requirements to ensure compliance

Injuries / Illness prevention program – Handwashing program included with policy update – this is a focus related to SB 158

Training of staff has been a key focus

HITECH Act

Biggest change to HIPAA requirements to date

Defines unsecured electronic PHI Outlines reporting requirements for breaches

of unsecured PHI Outlines reporting requirements for business

associates

Policy 2030 has been updated to comply with the business associate requirements for reporting of breaches.

All BA agreements need to be updated.

SB541 and SB337

SB 541 requires notification of the department within 5 days of discovery of an unauthorized disclosure of PHI

SB 337 modifies this requirement to mean 5 “business days”

Both Adminsitrative and HIM policies have been updated

POLST

A new policy for those facilities / areas using POLST

Policy includes physician order part and the requirements

Flow chart of steps required from the facility included

Red Flags

Policy developed for Red flags/ Identity theft prevention program.

Facility must have a program in place to detect possible medical identity theft

Program must be reviewed and approved by Adminsitrator.

Principles of documentation

Willful Omission and Willful Falsification of Records….

How to Avoid the Risks

Every entry is recorded promptly after the care/tx is given, i.e., for medications/treatments the documentation is done at the time of the med/tx

Food intake, at the end of the meal Intake and output – at the time

of measure of the intake and the output

ENTRIES

Complete, concise, accurate!!accurate!! Made by the person carrying out the care/tx

(not by another person for someone else) MDS signatures must be by the assessor for instance

Chronological– Used abbreviations only if approved by the facility

and in the manuals

In black or dark blue ink or typewritten Must be capable of being copied Must be legible Highlighters may cause obliteration when copied –

recommend against use. Include date, month, year and time if appropriate Signed by appropriate person with professional title,

i.e., C.N.A., R.N., L.V.N.

Do Not Use– White out, write over an entry, black out an entry– Sign for another person– Copy records or completing any portion of a

record without your personal knowledge the care was given, the data is accurate. Otherwise this could be construed as “falsification of records”

Do not leave blank spaces Do not document before an entry occurs

Corrections

Records may be corrected by drawing one line through the error, designate error, initial the error and chart the correct information with date and time if applicable.

Entries in the record shall be factual Accurately reflect the services provided to

the resident Accurately reflect the condition

of the resident Accurately reflect the resident’s response to

treatment and services

Willful Falsification

All staff shall be aware that an entry in the record that is made with the knowledge that the record falsely reflected the condition or situation is “willful material falsification”

Subject to civil penalty and $$…personally can be assigned to the employee

Be Alert to accurate Charting

All staff shall be aware that an entry in the record that is made with the knowledge that the record falsely reflected the condition or situation is “willful material falsification”

Subject to civil penalty and $$…personally can be assigned to the employee

Protecting the Integrity of the Record

How are you protecting your discharge records?

Collect all flow sheets immediately following discharge to avoid erroneous entries

Secure the record Any late entries made to the record must be

discussed with DON Any staff requiring access to the discharge

records must check out the record from the HIM department or DON’s office

Protecting the Records

Make sure all records removed from the nurse’s station are signed out

Always know the location of the records and who is accessing the information

Your AHIS Consultant

Will assist you with manual / policy updates Can assist with focused studies as part of QA Can assist with trending and analysis of audit

findings Can assist with staff training and in-services

Thanks for Attending