Have You Read YOUR Medical Record?

Association for Healthcare Documentation Integrity (AHDI) American Health Information Management Association AHIMA

Your Medical Record & Your Personal Health Record (PHR)

Quality healthcare begins with you, the patient.

What is a medical record?

 Encounter information from every health care provider  Separate file from each provider  Used for care and treatment planning  Legal document  Means by which patient and insurance company can verify that services billed were actually performed

Why should you want to read your medical record?

 Check for completeness  Request an amended report if there is an error and request a copy of the corrected (amended) report

What is a personal health record?

 A compilation and coordination of all healthcare encounters that enables individual providers to provide better care and continuity of care, i.e., information collected by the patient from their healthcare provider(s) compiled and updated as necessary for immediate access in case of a medical emergency.

Why would you want a PHR?

Come with me on a imaginary vacation. You may go anywhere you wish, this is your vacation……………(

presenter to insert a brief scenario where a PHR could assist when away from regular health providers)

Why do you need a PHR?

       Completeness of information Information scattered among multiple providers needs consolidation  Accuracy of information – no guesswork (medications and dosages, allergies, etc.) To provide medical information to new providers Better knowledge to assist in your own medical care Better quality of care; better coordinated care Medical emergencies Continuity of care

As well as….

 Natural emergency or disaster you can’t control (prime example – hurricane Katrina) a. Information may be misfiled b. Fire or flood, etc., can destroy records c. Older records can be stored in a manner that may deteriorate over time, i.e., microfilm d. Records stored on a computer could potentially be at risk if computer crashes e. Physicians sell their practices, retire, or even die  Traveling with no easy access to regular physician

And don’t forget………  New medical personnel with whom you have no relationship  Records are not kept indefinitely by providers

Whose information is the PHR anyway?

 Facility rights  Patient rights  HIPAA – Health Insurance Portability and Accountability Act Defines healthcare providers’ responsibilities/boundaries and patient rights

Accessing your medical record – how to obtain your information  Contact Health Information Management (the medical records dept.) in the facility or physician’s office  Ask for a release of information form, complete it and submit  http://www.myphr.com/  Start collecting and organizing information

Will you have to pay for copies of your medical records?

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Presenter to insert their particular state’s guidelines

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d.

e.

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g.

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Storing your information for easy accessibility Paper 3x5 cards Jewelry (necklace or bracelet) Computer CD DVD Thumb drive Plastic bin kept in one spot so it is easily grabbed

A final option  i. Outsource (accomplished by someone other than you) – 1. When deciding to outsource, weigh pros and cons, i.e., rate your own technology savvy skills, organizational skills, etc.

– 2. What measures have been taken by outsource choice to keep your personal health information (PHI) totally secure – 3. Check references for greater peace of mind

BACK IT UP!!!!

No matter how you decide to store your PHI be sure you have a backup.

Take your PHR with you to all medical visits  If you haven’t seen your primary care physician (PCP) for 6 months to a year, an updated medical history will be requested  Seeing a new physician for the first time, new health history forms will be requested

Carry card or wear jewelry with vital medical information  Medic Alert bracelet or necklace probably the easiest to access/find during an emergency. Information contained on that is limited due to size.

Safe and confidential  Your PHI is very confidential and it is very important that you keep it safe and restrict access to those predetermined by you.

What information should be contained in your PHR?

 Name, date of birth, address  Emergency contact(s) information  Names, addresses, phone numbers and specialty of healthcare providers  Health insurance information  Living wills, advanced health directives, or medical power of attorney  Organ donor authorization

 Important events, dates, heredity conditions in family and social history (history of drug addiction, alcoholism, etc.)  Results from a recent physical examination, illness, hospitalization  Functional status

MEDICATIONS!!!

 Current medications Prescription Nonprescription (over-the-counter and    herbal)   Medications taken in the recent past Special instructions given to you regarding medications Stop and start dates Reason for medication use Brand name or generic drug

ALLERGIES!!

 Allergies or sensitivities to drugs or materials (such as latex)  Food allergies (wheat/gluten, eggs, nuts)

Name of drug stores, pharmacists, and phone numbers For safety’s sake, use the same pharmacy for all your medications (drug interactions can be spotted immediately, possible allergies, etc.)

Other important information  Immunizations and their dates  Medical equipment used (CPAP machine, oxygen)  A list with dates of significant illnesses and surgical procedures  Opinions of specialists  Important test results (angiogram, cardiac stress test, EKG, etc.)

 Correspondence between patient and provider(s)  Chronic conditions such as diabetes, high blood pressure, etc.

 Eye examinations  Dental records  Permission forms for release of information, operative permits and other medical procedures

 Copies of correspondence (letters from one medical provider to another – request a copy be sent to you)

Checking for accuracy and completeness of your medical record

 Read over the data carefully  Arrange information chronologically for easy access  Make sure medications, doctor visits and tests are up to date

Internet Services (to name a few)  Microsoft www.healthvault.com

 BSC Healthcare www.myhealthfolders.com

 Google (yet to launch)

Online Service Requirements  Internet access  Computer  Fees (probably yearly)

Possible Risks  Internet services are not covered by HIPAA regulations  Could patients be easy targets of vendors wanting to sell treatments for ailments noted in their records?

 Will Congress extend the HIPAA protections to cover such services?

Where do you start/go for help?

 Forms available on the Internet, pharmacies and healthcare providers  AHIMA website www.myphr.com

 Association for Healthcare Documentation Integrity (AHDI) www.ahdi.org

To your good health!