Medical Record and Document Management

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Excelas had the opportunity to attend “Medical Records/Document Management – To Produce or Not To Produce?” which was a webinar presented as part of the Senior Living Empower Hour by the Adelman Law Firm.  Rebecca Adelman provided an overview of the importance of policies and procedures, compliance and training, and complaint response in record retention and release practices as part of a comprehensive risk management program.

Ms. Adelman noted that the medical record is “exhibit 1,” and long-term care facility staff must be trained in policies and procedures related to managing medical record requests and release of records.  Any request for medical records should initiate communication through the organization that there could be potential for future litigation.

A review of HIPAA, HITECH, and the 21st Century Cures Act provided key points that facilities must understand about a patient’s Right of Access and the requirements the facility must follow when releasing medical records.  The Office of Civil Rights enforces the HIPAA Right of Access, stating the goal of this initiative is to “vigorously enforce the rights of patients to receive copies of their medical records promptly and without being overcharged.”  Ms. Adelman indicated there has been a significant increase in complaints and enforcement actions, with total fines assessed by OCR through January 2023 exceeding $2.4 million.

She provided a review of the process to respond to medical record requests, what is and is not included in the Designated Record Set, who has the authority to request medical records, and form and format of releasing protected health information (PHI).  She also discussed a litigation hold and spoliation and the importance of having a litigation response team and plan.

In summary, Ms. Adelman recommends a proactive approach to risk management in handling medical record requests, which includes comprehensive and current facility-specific procedures, access to state and federal regulations, training and ongoing education for staff, audits, a formal retention schedule and quality assurance involvement.  The Excelas team, particularly our AHIMA accredited health information management professionals, understands the critical nature of ensuring that protected health information is disclosed in accordance with all state and federal laws and that healthcare organizations have current policies and procedures on release of information.  Excelas appreciates the legal insight provided in this webinar.

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