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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