A 45 -year-old female has requested a copy of her 80-year-old father’s health record. She has presented POA and has a legal right to access his records. You provide a copy to the woman, but she has many questions regarding documentation of her father’s diagnosis. He was admitted to the ICU last week from the skilled nursing facility. When discharged, he was transferred to a LTCH. In a brief written response to the woman, relate the components of the health record that supports diagnosis and reflects the patient’s progress, clinical findings, and discharge status. Explain the documentation used for these purposes within skilled nursing

facilities, ICU, and LTCH.

Reference

HIPAA Compliance Manual for Employers

J. Keller &, A. (2011). HIPAA Compliance Manual for Employers. Neenah: J. J. Keller & Associates, Inc.

Reference

Handbook for HIPAA/HITECH Security

Amatayakul, M., & American Medical, A. (2013). Handbook for HIPAA/HITECH Security. [Chicago, Ill.]: American Medical Association.

Reference

The Definitive Guide to Complying with the HIPAA/HITECH Privacy and Security Rules

Trinckes, J. J. (2012). The Definitive Guide to Complying with the HIPAA/HITECH Privacy and Security Rules. Boca Raton, FL: Auerbach Publications.

Reference

Communication Strategies for Healthcare Workers.

5 Communication Strategies for Healthcare Workers. (2015). Healthcare Executive, 30(6), 42.

Reference

ENHANCING COMMUNICATION BETWEEN PATIENTS AND HEALTHCARE PROVIDERS: SBAR3.

EClochesy, J. M., Dolansky, M. A., Hickman, R. J., & Gittner, L. S. (2015). ENHANCING COMMUNICATION BETWEEN PATIENTS AND HEALTHCARE PROVIDERS: SBAR3. Journal Of Health And Human Services Administration, 38(2), 237-252. NHANCING COMMUNICATION BETWEEN PATIENTS AND HEALTHCARE PROVIDERS: SBAR3.

Reference

Healthcare reform, EHRs, and adolescent confidentiality: regulations are becoming more complicated and vary by state

Taylor, J. F., Williams, R. L., & Blythe, M. J. (2015). Healthcare reform, EHRs, and adolescent confidentiality: regulations are becoming more complicated and vary by state. Contemporary OB/GYN, (8). 34.

 

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