Easily Delete Conditional Fields to the Medical Records Release

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How to Delete Conditional Fields to the Medical Records Release

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good afternoon everyone my name is Teresa wok and Im a partner here at Holland Hart in the Denver office welcome to our webinar series todays topic is medical records were going to talk about a variety of different things related to medical records so thanks for joining us I have a lot of slides some of them are I wont take long to go through but we still have a lot of information to cover so Im going to get right into it as always we have this is being presented as part of an educational series and to prevent to give you general information on these pertinent legal topics and we try to do the best we can to give you the relevant information that we think is going to help so the overview of what were going to talk about today were going to talk about the documentation and content of medical records and kind of included in that were going to talk about CMSs regulations and interpretive guidelines for medical records well talk about making revisions additions or corrections t

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Got questions?

Below are some common questions from our customers that may provide you with the answer you're looking for. If you can't find an answer to your question, please don't hesitate to reach out to us.

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What is the acceptable way to correct an error in a health care record?

When an error is made in a medical record entry, proper error correction procedures must be followed. Draw line through entry (thin pen line). Initial and date the entry. State the reason for the error (i.e. in the margin or above the note if room). Document the correct information.

Which exception can be made for release of patient medical information?

The HIPAA Privacy Rule contains an exception for law enforcement purposes1 that permits a covered entity to disclose PHI to law enforcement officials without patient authorization under the following circumstances: If there is a court order, court-ordered warrant, subpoena or administrative request.

Can things be deleted from medical records?

If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.

Which of the following are steps to take when correcting an error on a medical record quizlet?

DRAW A SINGLE LINE THROUGH THE ERROR. INSERT THE CORRECTION ABOVE OR IN THE MARGION OF THE ERROR. WRITE ERROR NEXT TO THE ERROR AND SIGN AND DATE THE MISTAKE.

What is the proper way to correct a medication documentation error?

Draw a single line through the erroneous entry and write the time, date, and your name. Identify the reason for the correction. Include the rationale in your notation; for example, mistaken entry, wrong medication name written. Follow facility policy when adding late information.

What are 3 things you should not add to a medical record?

The following is a list of items you should not include in the medical entry: Financial or health insurance information, Subjective opinions, Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,

Is it acceptable to delete a portion of a medical record to correct an error?

Nothing can be erased because medical records are legal documents. However, you can request an amendment that addresses the error so the info reflected is accurate. You can do this verbally, but my advice is to do it in writing.

Can you delete things from your medical record?

If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.

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