Methodist Healthcare Policy and Procedure Manual

The terms medical record, health record, and medical chart are used interchangeably when describing the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. Medical records includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc, according to an online dictionary. A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. “The U.S. health care system is in the midst of transforming from a fee-for-service system to a value-based system that delivers high-quality and cost-effective care.” (Koltov, M. K., & Damle, N. S. 2014) According to, the Handbook for Physicians and Medical Office Staff handbook, liability insurers, defense attorneys, and third-party payers remind physicians and other health professionals that the safety of patients, the outcome of litigation and the promptness of reimbursement depend on the adequacy, legibility, completeness, timeliness and accuracy of medical records. Firstly, medical records documentation is important for multiple reasons and has various operational and functional roles in the medical industry. Patient safety and provider protection are both protected by the information that is captured in the patient’s medical record. Every time you visit a hospital, physician or other health care provider, a record of your visit is made. This record may include your symptoms, examination and test results, diagnosis, treatment and plans for future care or treatment. Secondly, Methodist Healthcare organization addresses these issues by fostering the concept of top quality and continuity of care. Methodist Healthcare organization creates a means of communication between it’s’ providers and members about patient’s health status, preventive health services, treatment, planning, and delivery of care. In addition, Methodist Healthcare medical record standards reflect the importance of confidentiality and accessibility by authorized users only. Methodist healthcare weaknesses unfavorably are within the ability to oversee and manage risk management concerns relating to the mismanagement of records or improper disclosure of protected health information (PHI) that can lead to regulatory sanctions, network exclusions, and could affect licensure, accreditation, and Medicare and Medicaid reimbursement and participation. Medical records aide physicians in medical malpractice claims management and loss prevention activities. Upon any request being made, a complete documentation of any medical encounter must be made available. Promotion of continuous quality improvements includes good sound record documentation standards that reflect the importance of complete, timely, and accurate health information and are as follows: Member identifiers appear on every piece of documentation Entries are legible to others and are recorded in black or blue ink if on paper Entries are dated and authenticated by the author Documentation is made at the time service is provided Documentation must support all codes submitted Only standard medical abbreviations should be used in documentation All patient encounters, including telephone, fax, and electronic message exchanges are documented Documentation of any advance directives is in a prominent part of a member's medical record and includes whether or not a member has executed an advance directive, as well as documentation of any information about advance directives that was made available to the member Promptly forwarding the records ensures that the personal physician has a complete medical record on file The strength of Methodist healthcare is the ability to ensure compliance with laws, rules and regulations, and other benchmarks such as healthcare policies and procedures, Methodist healthcare managers are able to protect against unauthorized access and release, medical record management policies should address the physical security of paper-based documents, electronic record system security measures, and personnel access to both electronic and paper records. Methodist healthcare has a significant number of policies and procedures to cover all of the requirements that need to be covered. Certain responsibilities that meet and exceed customer expectation are as follows: Maintaining the privacy of your health record; Providing you with a copy of this Notice; Abiding by the terms of this Notice; Notifying you if we are unable to agree to a requested amendment or restriction; and Accommodating reasonable requests you may have to communicate health information by alternative means or at alternative locations. In conclusion, sound medical record documentation is important because it is being governed by gobs of laws on both state and federal levels. Medical records contain sensitive information, and increasing computerization and other policy factors have increased threats to their privacy. There are threats to privacy from modern record-keeping systems and from legislation. “Electronic health record systems contain clinically detailed data from large populations of patients that could significantly enrich public health surveillance.” (Vogel, J., Brown, J. S., Land, T., Platt, R., & Klompas, M. 2014) In order to protect patients these protectors have been established and are as follows:  Medical Ethics  The privacy portion of the Hippocratic Oath: "Whatsoever I shall see or hear in the course of my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets."  The 1992 AMA statement, which states that medical information must be confidential to the greatest possible degree.  Laws and Other Legal Protection  The Privacy Act of 1974, which states that no federal agency may disclose information without the consent of the person. Agencies must also meet certain requirements for protecting the information. Federal Laws only cover federal agencies, such as Medicare and Medicaid. The bulk of medical records are covered by various, inconsistent and often ineffectual state laws. State Laws , this document allows you to look at the privacy laws, including medical privacy laws, for each state. Only about half of the states guarantee patients the right to see their medical records (CR, Oct. 1994, p. 629). You can obtain more information by looking in your state code or by contacting Privacy Journal.  Tort Law. This may include defamation, breach of contract, and other privacy-related torts. To determine whether your policies comply with state and federal laws regarding the storage and release of PHI, consult with an attorney about the following issues: Creating policies and procedures pertaining to both the on-site and off-site storage of medical records. Accurately labeling and storing records to aid in record retrieval and prevent improper access and/or destruction. Establishing functional redundancy to allow for medical record storage system back-up should the primary storage system fail Entering into Business Associate Agreements with any outside vendors with whom the practice may contract to store, retrieve, and/or destroy medical records on behalf of the practice. Tailoring policies and procedures to address special considerations pertaining to the electronic medical records (e.g., protections by password and encryption, storage and protection of metadata, etc.). Nevertheless, the biggest challenges are with implementing and using electronic medical records. Healthcare providers are experiencing difficulty with using the new systems and therefore, seek other individuals to enter the data into the systems for them. “A failure by physicians to take a lead on this will mean that they may become victims of pressure or legislation.” (Patrick, K. 2014). Documenting the information on both paper and in a computer system has overwhelmed some providers. Furthermore, the lacks of familiarity with the systems have impeded the progress and therefore some users are reluctant to the change. However, opportunities for improvements are possible if the providers will buy into the quality initiative and get the best results out of the system. References 1.) Patrick, K. (2014). Patients and their medical records: it is time to embrace transparency. CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne, 186(11), 811. doi:10.1503/cmaj.140834 2.) Koltov, M. K., & Damle, N. S. (2014). Health policy basics: physician quality reporting system. Annals Of Internal Medicine, 161(5), 365-367. doi:10.7326/M14-0786 3.) Vogel, J., Brown, J. S., Land, T., Platt, R., & Klompas, M. (2014). MDPHnet: Secure, Distributed Sharing of Electronic Health Record Data for Public Health Surveillance, Evaluation, and Planning. American Journal Of Public Health, 104(12), 2265-2270. doi:10.2105/AJPH.2014.302103