Professional Documents
Culture Documents
03.03 Documentation and Confidentiality Worksheet
03.03 Documentation and Confidentiality Worksheet
03.03 Documentation and Confidentiality Worksheet
The amount and detail of information written in the documentation must reflect the exact
subjective, objective, assessment, and plan information for each patient. This is known as SAOP
note.
Handwriting
Proper use of grammar
Proper use of formatting
Confidentiality
The health Insurance portability and accountability act was passed by the united states federal
government which allows patients to decide how their medical records are used and who has
access to them.
The patient’s bill of rights is a list of rights that explains what health care a patient should
receive and how they should be treated under the medical care of professionals.
Three major objectives of the patient’s bills of rights are:
To strengthen consumer confidence and promote self-advocacy of care by assuring the
health care system is fair and responsive to consumer’ needs.
To reaffirm the importance of strong relationships between patients and their
healthcare professionals.
To establish rights and responsibilities for all participants to promote the critical role of
consumer- centered care.
High quality hospital care: Patients have the right to quality care and to know the identity of all
healthcare employees that will be treating them.
Involvement in care: Patients have the right to be involved in all decisions regarding their care.
A clean and safe environment: Patients have the right receive care in a clean and safe
environment that meets professional standards and requirements.
Protection of privacy: Patients have the right to privacy regarding their diagnosis, treatment,
and medical history.
Continuity of care: Patients have the right to share involvement with doctors regarding their
treatment plans, including available options when they leave the hospital.
Help with bill and filing insurance claim: Patients have the right to know each specific charge
from the hospital, as well as what payment methods are available to cover those charges.
HIPAA is a federal law that overrides state laws regarding the safety of medical information,
unless the state law has stricter regulations than HIPAA.
PHI- Protected Health information, is any information in a medical record that can be used to
identify an individual and that was created, used, or disclosed while providing a healthcare
service, such as a diagnosis or treatment.
PHU is personally identifiable information in medical records, including conversations between
doctors and nurses about treatment.
PHI also includes billing information and any patient-identifiable information and any patient-
identifiable information in a health insurance information management system
Examples of PHI:
Billing information from your doctor
Email to your doctor’s office about a medication or prescription you need
Appointment scheduling note with your doctor’s office
MRI scans
Laboratory test results such as outcomes from blood, urine, or body tissue tests
Phone records
Health insurance information.
HIPAA standard:
Administrative: policies and procedures that clearly demonstrate how health entities
and organizations will comply with HIPAA.
Ex:
Adoption of a written set of privacy procedures coordinated by a privacy officer.
Clear restrictions on employee access to protected health information (PHI).
Ongoing training programs regarding the handling of PHI.
Physical: Controlling physical access to protect unauthorized access to protected data.
Ex:
Network security for hardware and software.
Controlling access to hardware and software with PHI.
Monitoring access to PHI
Policies to regulate workstation and data use.
Technical: Controlling access to computer systems and communications containing PHI
over open networks.
Ex:
Protecting PHI from intrusion
Monitoring unauthorized changes or deletions of PHI
Ensuring data integrity such as authentication of information
Maintaining documentation of HIPAA practices to ensure legal compliance.
Advance Directives:
An advance directive allows healthcare providers to know a person’s specific wishes in the event
they are incapacitated and unable to relay those wishes.
Living will: a document that lets people state their wishes for end-of-life medical care in
case they become unable to communicate their decisions. It has no power after death.
A living will must be signed when that person is fully aware of the decisions they are
making. There must be two adult witnesses who are not involved in any decisions that
can result from the living will.
Power of attorney: a legal document that assigns another person with the responsibility
of making decisions on their behalf if the patient is unable to do so due to their medical
conditions.
o Can range from using funds, receiving treatments or procedures, or deciding
whether the patient should be kept alive.
o For must be signed by the patient, the person who will gain legal
responsibilities for decisions, two adult witnesses, and in most states signatures
on this document must also be notarized by a notary.
o The person who becomes responsible for making those decisions is known as
the designation of healthcare signature.
DNR (Do Not Resuscitate): A request to not have CPR (Cardiopulmonary resuscitation) if your
heart stops or if you stop breathing while you are in a medical facility. An out-of-hospital DNR is
for people who do not want to be resuscitates if they have problem at home or anywhere
outside of a medical facility.
Organ and tissue donation: Allow organs or body parts from a generally healthy person who has
died to be transplanted into people who need them.
Informed Consent: