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HAS 104F, Unit 1
AF Medical Records Management
| Term | Definition |
|---|---|
| Health Insurance Portability and Accountability Act (HIPPA) | Was enacted on Aug 21, 1996 and its purpose is to improve the portability and continuity of health insurance coverage, access to long term care, and simplify administration. |
| 6 Basic rules that HIPPA set forth | 1. Use of Information 2. Acknowledgement of Notice of Privacy Practices (NoPP) 3. Disclosure of Release 4. Patient rights to access 5. Accounting of disclosure 6. Restrictions on Information |
| Use of Information | Patients PHI can only be used for treatment, payment, and health care operations. |
| Acknowledgement of Notice of Privacy Practices (NoPP) | Each patient will receive MHS NoPP. |
| Disclosure or Release | Records may be disclosed without authorization for reasons such as subpoena, court order, or public health request. |
| Patient rights to access | The record is the property of the US gov, the information in the record belongs to the patient, therefore patient can copies of info in the record. |
| Accounting of disclosure | Patient can request an accounting of previous disclosures. |
| Restrictions on information | According to HIPAA and MHS NoPP, the patient has the the right to request restrictions of uses and disclosures. |
| HIPAA Violation, Civil Penalty | You didn't mean to violate HIPAA, but you still have to be heald responsible. Not less than $100 for each violation. |
| HIPAA Violation, Federal Criminal Penalty Wrongful Disclosure | Up to $50k and 1 year in prison. |
| HIPAA Violation, Federal Criminal Penalty False Pretences | Up to $100k and up to 5 years in prison |
| HIPAA Violation, Federal Criminal Penalty Commercial Advantage Personal Gain Malicious Harm | Up to $250k and up to 10 years in prison. |
| Protected Health Information Management Tool (PHIMT) | HIPAA Privacy Officer will establish mechanisum that tracks disclosures of PHI. PHIMT is the prefered method to document all accountable disclosures. Disclosure record must be maintained a minimum of 6 years. |
| Accounting of Disclosures | Patient may request an accouning of every disclosure except for uses of PHI for treatment, payment, or healthcare. They will receive disclosures related to law enforcement, public health, and legal situations. |
| A written accounting for each disclosure will include | When- date of disclosure Who- name of the person or entity to received disclosure What- a brief description of PHI Why- statement of purpose of disclosure |
| Privacy Act and Freedom of Information Act Medical Personnel Must... | Comply with laws affecting MAINTENANCE and DISCLOSURE. |
| Laws affecting MAINTENANCE and DISCLOSURE. Planes Fly High During Combat | Planes- Privacy Act Fly- Freedom of Information Act High- Health Insurance Portability and Accountability Act During- Drug Abuse Offense and Treatment Act Combat- Comprehensive Alcohol Abuse amendments. |
| Privacy Act of 1974 | Made to protect personal information. Personal information is defined as information that could result in harm, embarrassment, inconvience or unfairness if it is lost, compromised or disclosed. |
| Two forms are used to inform the patients of their rights. | DD Form 2005 privacy act statement, and the MHS NoPP. The DD Form 2005 privacy act statement is printed on the back cover of the AF Form 2100A record folder. These two forms are not consent forms and are not required to be signed by the patient. |
| Patient acckolagemnt of the 2005 privacy act statement and MHS NoPP. | The patient, parent, or guardian must be asked to sign, but they are not consent forms and signature is not required. |
| What are the federal criminal penalties for knowingly violating patient privacy? | -Wrongful Disclosure: Up to $50k and 1 year in prison. -False Pretences: Up to $100k and up to 5 years in prison -Commercial Advantage, Personal Gain, Malicious Harm: Up to $250k and up to 10 years in prison. |
| What document must each patient at the MTF be given a copy of? | MHS NoPP and Privacy Act Statement |
| Who maintains the overall responsibility of ensuring all personnel with access to protected Health Information receive HIPPA training? | The MTF Commander |
| What is the prefered method to document all accountable disclosures of PHI? | PHIMT- Protected Health Information Management Tool |
| What are the DD Form 2005 Privacy Act Statement and the MTS NoPP used for? | They are used to inform patients of their rights under the privacy act of 1974. |
| True or False, DD Form 2005 Privacy Act Statement na dhte MHS NoPP are a type of consent form. | False |
| True or False, Signature of the patient on the MHS NoPP label is mandatory. | False |
| Ownwehip of Medical Records | Medical Records are property of the US gov, the information in the record belongs to the patient. Maintenance of the record at the MTF is a legal requirement. The MTF Commander is the ultimate custodian and responsible for all records. |
| Outpatient record management | MTF must establish custody. Ensure patients do not leve the MTF with their records. |
| Method for retrieving records that are taken by the patient. | 1. Contact the patient. 2. Notify Sponsor's chain of command. 3. send a certified letter to the patient requiring the return within 10 days. 4.10 days after patient recieves request and if the record is still not returned, contact security forces |
| Outpatient records charged out or borrowed. | Records may be charged our or borrowed by internal MTF but should be returned by EOD and NLT 72 Hours after treatment. |
| Safeguarding medical information | The patients medical record is personal, confidential, and must be safeguarded. Outside agencies must have a valid requirement to access records. |
| Sensitive medical information | Defined as medical information which may affect the patient's morale, character, medical progress, or mental health. Documents must be stamped and accessed by authorized personnel only. |
| Release of Medical Information | DD Form 2870- Authorization for Disclosure of Medical or Dental Information Minors- Legal guarden Deceased persons- Next of kin Physically or mentally incompetent- proof or guarduanship |
| Release of Information- non-military sources | may be released to civilian providers and hospitals for the purpose of further diagnosis. |
| Release of medical information request approval | MTF commander is the approver but they may delegate responsibility. They only provide enough information to accomplish the purpose for which the information was requested. |
| Request of medical information for legal matters | Consult the Legal Office or Staff Judge Advocate. The Criminal Investigation Department (CID) or Office of Special Investigation (OSI) are DOD investigative agencies which may request a patients medical information. |
| Commanders Designee Process | Commanders and their designee's may access active duty personnel medical records for the purpose of military mission. Designees: -Vice Commander -Deputy Commander -First Sergeant |
| Release of Medical Information to Government Departments or Non-DOD Agencies | Other departments may request medical information and they must have a legitimate need for it. -Department of Veterans Affairs (DVA) -Federal or State Hospitals and prisons -Occupational Safety and Health Administration (OSHA) |
| Release of Medical Information for research purposes | PHI may be released for medical research or scientific reasions when it legal and in the public interest. Must remove: -name -SSN -other demographic info |
| Release of Medical Information to the Public | Consult with Supervisor and Public Affairs Office |
| Medial Information Release to the Public WITHOUT Consent of Patient | -Unit Assignment -Office where member works |
| Medial Information Release to the Public WITH Consent of Patient | -Name and Rank -Occupation or Job Title -Present medical assessment of condition |
| Medial Information Release to the Public, what should you never release? | Sensitive Medical Information |
| Health Records are property of whom? | The US government |
| What steps should you take if an individual is holding their medical records at home? | 1. Contact the patient. 2. Notify Sponsor's chain of command. 3. send a certified letter to the patient requiring the return within 10 days. 4.10 days after patient recieves request and if the record is still not returned, contact security forces |
| When should medical records be returned to the outpatient records section? | Same day, but NLT 72 hours after patient treatment. |
| Information in the medical record is __________, __________ and must be propperly ____________. | -Personal -Confidential _Safeguarded |
| Define Sensitive Medical Information | Information that could affect the patient's morale, character, mental progress, or mental health. |
| What form is used to disclose medical and dental information? | DD Form 2870 |
| True or False: Information that is released to a third party (such as insurance companies, civilian physicians, etc.), may be further released without consent. | False |
| Who should you consult before discussing official military information with the public? | Public Affairs |
| What information is never to be released to the public? | Sensitive Medical Information |
Created by:
crystaljoy