can i include patient initials in report?

It is not a HIPAA violation to email patient names per se, although patient names and other PHI should not be included in the subject lines of emails as the information could easily be viewed by unauthorized individuals.

Full Answer

What should each hospitalist report for their first encounter with the patient?

On day two, another hospitalist, Dr. B, who works in the same HM group, sees the patient for the first time. What should each of the physicians report for their first encounter with the patient? Each hospitalist should select the CPT code that best fits the service and their role in the case.

What details should be included in a medical record?

For instance, the details of a complicated series of procedures, such as a primary surgery followed by a set of follow-up surgeries and examinations, for a person of a certain age and gender, might permit the recipient to comprehend that the data pertains to his or her relative’s case.

Are patient initials HIPAA compliant?

Then, is using patient initials Hipaa compliant? A client's initials are considered to be identifying for the purposes of determining if a given piece of information is PHI under HIPAA, because they are derived from names. This doesn't mean that using client initials instead of their full names isn't helpful.

Is it required to remove additional information from patient records?

Whether additional information must be removed falls under the actual knowledge provision; the extent to which the covered entity has actual knowledge that residual information could be used to individually identify a patient.

Is it a HIPAA violation to use initials?

Q: Are an individual's initials considered to be identifiers under the Privacy Rule? A: Yes, because an individual's name is an identifier and initials are derived from the individual's name, initials are considered identifiers under the Privacy Rule.

Are patient initials protected health information?

With respect to the safe harbor method, the guidance clarifies whether specific data need to be removed from a given data set before it can be de-identified. It notes that derivations of one of the 18 data elements, such as a patient's initials or last four digits of a Social Security number, are considered PHI.

How do you write patient initials?

Patient initials: A reporter should only mention the initials of a patient instead of the full name. For e.g.: Madhu Gupta should be written as MG. 2. Age at time of event or date of birth: A reporter must report either the date of birth or age of the patient at the time the event or reaction occurred.

Is a patient name a HIPAA violation?

It is not a HIPAA violation to email patient names per se, although patient names and other PHI should not be included in the subject lines of emails as the information could easily be viewed by unauthorized individuals.

Are initials considered PII?

Personal Identity Information (PII), also known as P4 data, is a specific category of particularly sensitive data defined as: Unencrypted electronic information that includes an individual's first name or initial, and last name, in combination with any one or more of the following: Social Security number (SSN).

Is patient name alone considered PHI?

Names, addresses and phone numbers are NOT considered PHI, unless that information is listed with a medical condition, health care provision, payment data or something that states that they were seen at a particular clinic.

What are patient initials?

PATIENT INITIALS is the same as attribute PERSON NAME WORD TEXT where the PERSON NAME WORD TYPE is National Code 'Person Initials'. PATIENT INITIALS is the PERSON INITIALS of the PATIENT.

What is the proper way to identify a patient?

Patient identifier options include:Name.Assigned identification number (e.g., medical record number)Date of birth.Phone number.Social security number.Address.Photo.

What is not considered PHI under HIPAA?

PHI only relates to information on patients or health plan members. It does not include information contained in educational and employment records, that includes health information maintained by a HIPAA covered entity in its capacity as an employer.

Is it a HIPAA violation to talk about a patient without identifiers?

HIPAA violation: yes, because someone might still be able to identify that person hearing the information. Going down an elevator, physicians are always reminded not to discuss care even without patient identifiers.

Can you talk about a patient without saying their name?

Forbid any reference to the client's first name, last name, or description to protect their identity. It doesn't just stop at talking about patients without using names, there's more that needs to take place. Obviously, continue to reiterate that gossiping about patients isn't allowed at your practice.

What is the most common HIPAA violation?

Snooping on healthcare records of family, friends, neighbors, co-workers, and celebrities is one of the most common HIPAA violations committed by employees.

What to Include on a Patient Care Report (ePCR)

Accurate patient data is arguably the most valuable tool a medic has at his or her disposal. It not only informs immediate treatment decisions, but it shows what is – and isn’t – working. It plays a pivotal role in efficient patient hand-off at the ED, and it dictates the type of care he or she will receive in the minutes and hours after.

ePCRs: Patient Care Reports for the 21 st Century

Over the last 30 years, EMS agencies and hospitals alike have recognized the value of going digital with patient records, coining the term “electronic patient care reports” (ePCRs).

About Patient Care Reports

Digital patient care reports are slowly but surely changing the way patient information is recorded on a call, but they do not change interactions with patients. Instead of jotting down notes on a paper form, medics quickly and easily record the same information using a tablet and a digital form.

What Patient Care Reports Should Include

Just like the paper version of patient care reports, ePCRs are meant to be complete and contain all pertinent information to help deliver proper patient treatment and track performance metrics.

Obstacles to Efficiently Creating Electronic Patient Care Reports

As the adoption of ePCRs has ramped up in the last three decades, technology has evolved along with it. However, technology includes its own set of challenges. Onboarding an entire EMS agency to a new records system takes a coordinated effort and can require a substantial investment in time and money.

Comparing Documentation Methods: SOAP vs. CHART vs. IMRaD

Accurate, complete, and rich documentation in patient care reports can improve patient outcomes, provide accurate claims processing, further quality assurance, and even defend against malpractice. Offering guidance on what elements to include in narratives can result in more complete run reports.

New ePCRs Improve Patient Care While Improving Analytics and Reporting

Today’s top ePCR software tools offer direct improvement to patient care by streamlining communication and reducing the chance for human error. For example, customized forms in the system can be progressive, meaning a medic cannot move on to the next field without recording data for all required fields first.

What is protected health information?

The Privacy Rule protects all "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. “Individually identifiable health information” is information, including demographic data, that relates to:

How to use character names?

We know you like to be extra safe, so here are the two best ways of using character names: 1. Put the fake name in quotes the first time you use it, then drop the quotes afterwards. This will help the reader understand that it’s made-up.

Is a phony name a violation of HIPAA?

So, you’re not violating HIPAA if you use a phony name and avoid divulging any of these key identifiers.

Is a patient's name protected by HIPAA?

Patient names (first and last name or last name and initial) are one of the 18 identifiers classed as protected health information (PHI) in the HIPAA Privacy Rule. HIPAA does not prohibit the electronic transmission of PHI. Electronic communications, including email, are permitted, although HIPAA-covered entities must apply reasonable safeguards ...

Is email considered HIPAA protected?

Electronic communications, including email, are permitted, although HIPAA-covered entities must apply reasonable safeguards when transmitting ePHI to ensure the confidentiality and integr ity of data .

Can you send a PHI email to an incorrect recipient?

Sending an email containing PHI to an incorrect recipient would be an unauthorized disclosure and a violation of HIPAA.

Why is documentation important for PHI?

The importance of documentation for which values in health data correspond to PHI, as well as the systems that manage PHI, for the de-identification process cannot be overstated. Esoteric notation, such as acronyms whose meaning are known to only a select few employees of a covered entity, and incomplete description may lead those overseeing a de-identification procedure to unnecessarily redact information or to fail to redact when necessary. When sufficient documentation is provided, it is straightforward to redact the appropriate fields. See section 3.10 for a more complete discussion.

What is the provision of health care to the individual?

the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual.

What is HIPAA protected health information?

The HIPAA Privacy Rule protects most “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or medium, whether electronic, on paper, or oral. The Privacy Rule calls this information protected health information (PHI) 2. Protected health information is information, including demographic information, which relates to: 1 the individual’s past, present, or future physical or mental health or condition, 2 the provision of health care to the individual, or 3 the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual. Protected health information includes many common identifiers (e.g., name, address, birth date, Social Security Number) when they can be associated with the health information listed above.

What is HIPAA Privacy Rule?

The HIPAA Privacy Rule protects most “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or medium, whether electronic, on paper, or oral. The Privacy Rule calls this information protected health information (PHI) 2.

Why is de-identification not protected?

De-identified health information created following these methods is no longer protected by the Privacy Rule because it does not fall within the definition of PHI. Of course, de-identification leads to information loss which may limit the usefulness of the resulting health information in certain circumstances.

What is implementation specification?

The implementation specifications further provide direction with respect to re-identification, specifically the assignment of a unique code to the set of de-identified health information to permit re-identification by the covered entity.

Can a covered entity disclose de-identified information?

No. The Privacy Rule does not limit how a covered entity may disclose information that has been de-identified. However, a covered entity may require the recipient of de-identified information to enter into a data use agreement to access files with known disclosure risk, such as is required for release of a limited data set under the Privacy Rule. This agreement may contain a number of clauses designed to protect the data, such as prohibiting re-identification. 30 Of course, the use of a data use agreement does not substitute for any of the specific requirements of the Expert Determination Method. Further information about data use agreements can be found on the OCR website. 31 Covered entities may make their own assessments whether such additional oversight is appropriate.

Which rule applies to all types of health information regardless of whether it is stored on paper or electronically?

While the protection of electronic health records was addressed in the HIPAA Security Rule, the Privacy Rule applies to all types of health information regardless of whether it is stored on paper or electronically, or communicated orally.

What happens to PHI under HIPAA?

Under HIPAA, PHI ceases to be PHI if it is stripped of all identifiers that can tie the information to an individual. If the above identifiers are removed the health information is referred to as de-identified PHI. For de-identified PHI, HIPAA Rules no longer apply.

What is future health information?

Future health information can include prognoses, treatment plans, and rehabilitation plans that – if altered, deleted, or accessed without authorization – could have significant implications for a patient. For this reason, future health information must be protected in the same way as past or present health information.

Is PHI a form of health information?

It is not only past and current health information that is considered PHI under HIPAA Rules, but also future information about medical conditions or physical and mental health related to the provision of care or payment for care. PHI is health information in any form, including physical records, electronic records, or spoken information.

Is health information considered PHI?

Essentially, all health information is considered PHI when it includes individual identifiers. Demographic information is also considered PHI under HIPAA Rules, as are many common identifiers such as patient names, Social Security numbers, Driver’s license numbers, insurance details, and birth dates, when they are linked with health information.

Is PHI covered by HIPAA?

That depends on the circumstances. Usually a patient will have to give their consent for a medical professional to discuss their treatment with an employer; and unless the discussion concerns payment for treatment or the employer is acting as an intermediary between the patient and a health plan, it is not a HIPAA-covered transaction. However, while not PHI, the employer may be required to keep the nature of the discussion confidential under other federal or state laws (i.e. ADA, FCRA, etc.).

Does HIPAA apply to education records?

A hospital may hold data on its employees, which can include some health information – allergies or blood type for instance – but HIPAA does not apply to employment records, and neither education records. Under HIPAA, PHI ceases to be PHI if it is stripped of all identifiers that can tie the information to an individual.

How long does a physician spend at the bedside?

Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit. Note: These codes are used for new or established patients (e.g., a patient who has received face-to-face services from a physician or someone from the physician’s group within the past three years).

What is 99221 - 99223?

Initial hospital-care services ( 99221 - 99223) require the physician to obtain, perform, and document the necessary elements of history, physical exam, and medical decision-making in support of the code reported on the claim. There are occasions when the physician’s documentation does not support the lowest code (i.e., 99221 ).

Do physicians have to spend time with patients?

The physician does not have to spend the associated “typical” visit time with the patient in order to report an initial hospital-care code. Time is only considered when more than 50% of the total visit time is spent counseling or coordinating patient care.