Applied Sciences

sing as references:

 

  • Joshi, M., Ransom, E. R., Nash, D. B., & Ransom, S. B. (2014). The Healthcare Quality Book : Vision, Strategy, and Tools. Chicago, Illinois: Health Administration Press.Chapter 6 “ Statistical tools for Quality Improvement”
  • Kruse, C. S., Kristof, C., Jones, B., Mitchell, E., & Martinez, A. (2016). Barriers to Electronic Health Record Adoption: a Systematic Literature Review. Journal Of Medical Systems, 40(12), 252.

and any other, respond:

Locate the licensure regulations for the state of Florida in the United States of America. What are the provisions for the content of a health record? What are the rules regarding the timeliness of completion of a record? Locate any state laws regarding health information or medical records for your state. Are there retention statues? Are references to the costs of providing copies of medical records? Share your thoughts on whether you feel these are quite liberal or too strict. Examine your state’s regulations in relation to some of your peer’s posts.

Using their same reference in two different paragraphs give your personal opinion to Felita Daniel-sacagiu  and Marla Stuck

Marla Stuck

Michigan Medical Records

Medical Records in Michigan for licensing purposes per MCL §333.16213 “must keep and maintain a record for each patient for whom he or she has provided medical services, including a full complete record of tests and examinations performed, observations made, and treatments provided” (Michigan State Medical Society, 2017). Other than this statute, there is no additional specificity of the content that must be part of the medical record.

Record Retention.

The medical record must be kept for seven years.  There are requirements for destruction or transfer of medical records covered in the same MCL §333.16213 statute that address the sale of practices and so forth.  Records must be kept in a manner that retains their confidentiality, integrity, and availability to patient’s access as provided by law.

Timeliness of Completion.

In the acute care setting, CMS regulations state thirty (30) days as the deadline for timeliness of record completion.  It might be challenging to remember all the pertinent information if records took longer than the near-immediate to complete.  Oaklawn will suspend provider privileges if their records are not complete within the thirty-day window.  Currently, CMS has waived this requirement, and according to our HIM Manager, there will be a lot of suspensions when the waiver is exhausted.

From other discussions and assignments, research shows this is different in long-term care settings.  Records must be initiated within 24 hours of admission and completed no later than 72 hours after that intake.  Plus, in the long-term care setting, the residents/patient’s record is on-going over their average 2-5 year stay.

Replication Costs.

Costs to provide copies of medical records in Michigan as retrieved from MDHHS site for 2020 fees:

(MDHHS, 2020)

The costs are based on the CPI for Detroit.  These prices are reasonable considering the wages of the employees that are making the copies.  The reason for the copies is probably for a lawsuit, so one may believe that cost could be recuperated in a lawsuit settlement.

It is interesting to learn after all the years, too, that the medical record belongs to the Provider or Healthcare Institution and not the patient.  Patients have access rights but not ownership—naive thoughts about information and who owns that information.

References

MDHHS. (2020, February 7). Medical Records Access. Retrieved from michigan.gov: https://www.michigan.gov/mdhhs/0,5885,7-339-73970_7701_76674—,00.html

Michigan Legislature. (2006, December 22). Public Health Code Act 368 or 1978. Retrieved from legislature.mi.gov: http://www.legislature.mi.gov/(S(srmy03y3qsk5ko4qyqgjeerm))/mileg.aspx?page=GetObject&objectname=mcl-act-368-of-1978

Michigan State Medical Society. (2017, July). Medical Records Guide for Physician Practices. Retrieved from msms.org: https://www.msms.org/DesktopModules/MSMS.AlertGuideChecklist/Guides/7/Medical_Records_Guide_2017.pdf

Felita Daniel-sacagiu

My State:  Tennessee

Licensing:  Tennessee Medical Records Act, T.C.A. §§ 68-11- 301, et seq.

Provisions for the content of a health record.  Medical records must include such items:

  • Patient identification (i.e. name social security number)
  • Medical history
  • How the patient feels at the time of visit
  • Family history
  • Results of examinations, test results
  • Treatment received during any hospital stays
  • X-ray records made by heart monitors or similar equipment
  • Medication prescribed
  • Physician notes
  • Other information that can affect patient health and/or healthcare

Additional requirements:

  • Entries should be made at the time of service or soon after
  • Entries must be dated
  • Corrections, clarifications, and addition of information that was not initially available should be made asap or within 24 hours of service
  • Errors must be legibly corrected, dated, and signed or initialed
  • Deleted items should have only one thin pen line drawn through them
  • The Joint Commission (JCAHO) strongly recommends against the use of abbreviations, acronym, and symbols to prevent confusing the patient

State Medical Record Laws:

  • Minimum medical record retention periods for records held by physicians and hospitals is 10 years from the providers’ last professional contact with the patient
  • Minor patients – 10 years from the providers’ last professional contact with the patient or 1 year after the minor reaches the age of 19
  • Tenn. Comp. R. & Regs. 0880-2-.15 (2008) – Adult patients 10 years following the discharge of the patient or the patient’s death during the patient’s period of treatment within a hospital
  • Tenn. Code Ann. §68-11-305(a)(1) (2008). Minor patients 10 years following discharge or the period of minority plus at least one year (i.e., until the patient turns 19)

Costs of copies (Physicians)

  • $20.00 for medical records 5 pages or less.  $0.50 per/page for each page copied after the first 5 pages
  • The actual cost of mailing

Costs of copies (Hospitals)

  • $18.00 retrieval fee for the first 5 pages of the record
  • $0.85 for pages 6-50
  • $0.60 for pages 51-250
  • $0.35 for pages 251 up
  • The actual cost of mailing

Share your thoughts on whether you feel these are quite liberal or too strict.

I was surprised to find out that a provider can impose an additional fee (legally) if a patient requests a summary or explanation of his or her health information in addition to copies of health information.

Health IT Dashboard Catalog. (May 2020). Retrieved from https://dashboard.healthit.gov/help/dashboard-catalog.php

Legal Issues in Healthcare (December 2007). Retrieved from = https://www.uthsc.edu/Medicine/legaledu/UT/factsheets/MedicalRecords.pdf

Statutes and Rules. (n.d.). Retrieved May 18, 2020, from https://www.tn.gov/health/health-program-areas/health-professional-boards/me-board/me-board/statutes-and-rules.html

 

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