A sample reference for HIPAA policy and procedure compliance for any facility:
The government has agencies that monitor and enforce HIP compliance all over the United States. A good rule of thumb would be to fully understand the following information in order to remain legally compliant with the current laws:
€ General rules for HIPAA
€ HIPAA uses and any of its disclosures
€ A patient or resident's legal rights covered under Hippa
€ Other information about hipaa policies and procedures government requirements
€ The retention and destruction of any Hippa documentation
1. One of the general rules would be to understand that any resident has to be legally permitted to obtain a copy of their privileged health information. A resident may also obtain or request additional amendments to their protected health information or their (€PHI€). This policy rule will document any contents of a resident's Designated Record Set at any given location.
2. A Designated Record Set may be a resident's medical records stationed with a facility when they may have been seen as a patient or resided for a brief period for rehabilitation or other hospital stay of some sort. These designated record could include a resident's medical or billing records that may have been used in a decision making process of some sort regarding the patient or resident. The definition of the word record may be defined as a group of items, a patient or resident's collection or information group that could include any €PHI€ or privileged health information. These €PHI€ groups or collections are always disseminated and maintained by the designated facility.
3. A facility always keeps a resident's following Designated Record Set by:
€ A patient and/or resident's Medical File
€ A patient and/or resident's Business Record and,
€ A patient and/or resident's Personal Health Information.
4. A patient and/or resident's Medical Information could include any of the below mentioned medical items:
€ Any medically active documents
€ Any admission and/or readmission medical information
€ Any of their advanced directives
€ Their medical flow sheets or their medical assessments
€ Their medical care plans
€ Any informed consent documentation
€ Their medication requirements and/or their treatment records
€ Any of their medical orders from physicians
€ Any medical reports from radiology, lab, or other diagnostic testing documentation
€ Any medical face sheets
€ Their social service medical documents
€ Their nursing progress notes or other nursing documentation
€ Any nursing notes or other nursing documentation
€ Any of their nutritional documents during their stay at the facility
€ A patient or resident's medical record may exclude photographs, film, strips used for monitoring their progress, video tapes, slides, microfilm, shadow files or other sources of data.
€ If any outside records are used in a patient or resident's treatment plan during their stay then they may also be considered part of the medical record.
5. A patient or resident's Business Record may include:
€ Their documents for admission
€ The receipt of the patient or resident's Notice of Privacy Act or Practices from the facility
€ Account balance statements
€ Any correspondence relates to their insurance coverage.
6. A patient or resident's Personal Health Information may consist of their medical or other privileged information given to the facility.
7. Some administrative data, such as any audit trails, may be excluded from a patient or resident's Designated Record Set.
8. The state and federal government requires a company maintain a Designated Record Set or other facility retention HIPAA policies and procedures.
The government has agencies that monitor and enforce HIP compliance all over the United States. A good rule of thumb would be to fully understand the following information in order to remain legally compliant with the current laws:
€ General rules for HIPAA
€ HIPAA uses and any of its disclosures
€ A patient or resident's legal rights covered under Hippa
€ Other information about hipaa policies and procedures government requirements
€ The retention and destruction of any Hippa documentation
1. One of the general rules would be to understand that any resident has to be legally permitted to obtain a copy of their privileged health information. A resident may also obtain or request additional amendments to their protected health information or their (€PHI€). This policy rule will document any contents of a resident's Designated Record Set at any given location.
2. A Designated Record Set may be a resident's medical records stationed with a facility when they may have been seen as a patient or resided for a brief period for rehabilitation or other hospital stay of some sort. These designated record could include a resident's medical or billing records that may have been used in a decision making process of some sort regarding the patient or resident. The definition of the word record may be defined as a group of items, a patient or resident's collection or information group that could include any €PHI€ or privileged health information. These €PHI€ groups or collections are always disseminated and maintained by the designated facility.
3. A facility always keeps a resident's following Designated Record Set by:
€ A patient and/or resident's Medical File
€ A patient and/or resident's Business Record and,
€ A patient and/or resident's Personal Health Information.
4. A patient and/or resident's Medical Information could include any of the below mentioned medical items:
€ Any medically active documents
€ Any admission and/or readmission medical information
€ Any of their advanced directives
€ Their medical flow sheets or their medical assessments
€ Their medical care plans
€ Any informed consent documentation
€ Their medication requirements and/or their treatment records
€ Any of their medical orders from physicians
€ Any medical reports from radiology, lab, or other diagnostic testing documentation
€ Any medical face sheets
€ Their social service medical documents
€ Their nursing progress notes or other nursing documentation
€ Any nursing notes or other nursing documentation
€ Any of their nutritional documents during their stay at the facility
€ A patient or resident's medical record may exclude photographs, film, strips used for monitoring their progress, video tapes, slides, microfilm, shadow files or other sources of data.
€ If any outside records are used in a patient or resident's treatment plan during their stay then they may also be considered part of the medical record.
5. A patient or resident's Business Record may include:
€ Their documents for admission
€ The receipt of the patient or resident's Notice of Privacy Act or Practices from the facility
€ Account balance statements
€ Any correspondence relates to their insurance coverage.
6. A patient or resident's Personal Health Information may consist of their medical or other privileged information given to the facility.
7. Some administrative data, such as any audit trails, may be excluded from a patient or resident's Designated Record Set.
8. The state and federal government requires a company maintain a Designated Record Set or other facility retention HIPAA policies and procedures.
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