Confidentiality, Privacy and Security

Guidance on Header Information for Legal Medical Record

  • 1.  Guidance on Header Information for Legal Medical Record

    Posted 06-27-2019 16:00
    Good afternoon.  I am asking for some assistance in identifying where it states that the forms or printouts from EHR's have the company name listed on them.  We have always placed our company name on forms and at one time during a review the reviewed sited us for not having our facility name listed on the form.

    This has come full circle as we bring on clinics, they want to see the standard that say our facility name needs to be listed on the information that is placed in the health record.

    Any help with this would be greatly appreciated.


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    Kimberle Johnson
    [Director HIM/Privacy and Compliance Officer]
    Campbell County Health
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  • 2.  RE: Guidance on Header Information for Legal Medical Record

    Posted 06-28-2019 08:59
    I have been doing this a very long time and I cannot recall a specific rule or regulatory requirement.  It certainly is a highly recommended best practice - primarily to identify where the services were provided.

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    Nancy Davis, MS, RHIA, CHPS
    Director of Compliance & Safety
    Door County Medical Center
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  • 3.  RE: Guidance on Header Information for Legal Medical Record

    Posted 06-28-2019 09:23

    Not sure you would find anything actually in a regulation, but I see this more as a "medical record sound practice."  I think each page of a patient's legal record should be able to stand alone and identify the facility where the document was created.  It there was a question or issue with the contents of a document, it would be apparent which facility to contact.....

     

    Wendy Mangin, MS, RHIA

    Executive Project Director – Regulatory Compliance/Privacy Officer

     

    Good Samaritan 

    520 S. Seventh St. | Vincennes, Indiana | 47591

    Hospital: 812.882.5220 | Direct: 812.885.3487 

    Fax: 812.885.3912 | wmangin@gshvin.org 

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  • 4.  RE: Guidance on Header Information for Legal Medical Record

    Posted 06-28-2019 09:36
    Thank you Wendy and Nancy.  That is what I was leaning towards.  I was also leaning towards the theory each record must stand on its own to support what was provided to the patient.  If it gets separated how do we know which facility performed the test.  I wish for the life of me what section the state reviewer sited us under to go review that section again.

    Kim


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    Kimberle Johnson
    [Director HIM/Privacy and Compliance Officer]
    Campbell County Health
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