The Health Information Management Services (HIMS) includes health policies that contain data relating to patients’ medical history, diagnoses, procedures, and outcomes. Good health policies are specially formatted to include decisions, plans, and actions in patient care and documentation of records. For electronic medical records, practitioners need authentication to gain access to patient information. This essay contrasts the Kansas and Banner County health department policies and documents how a health policy should be.
For both the Kansas and Banner counties’ health policies, the applicability of the policy is used in the protection of patients’ information. Both policies authenticate the steps taken by practitioners in safeguarding or accessing the medical records of patients. According to the Joint Committee on Administrative Rules of Illinois, under title 77 of the administrative code of medical records, a qualified health information practitioner should be employed as the director of the medical records department. This is necessary as the person will ensure any other health practitioner that wants access to patient records has proper authentication. All the entries into the medical records are authenticated by the individual who made the entry except an order authenticated by a practitioner to another practitioner responsible for the care of a patient. For electronic medical records, the hospital adopts the use of electronic signatures for staff to gain access to patent information.
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The Banner health policy accounts for the patient’s medical history before or after medical examination. The Kansas health policy has standing orders that use patient information where a nurse or practitioner can be authorized to administer treatment if a doctor is unavailable. In both cases, the documentation details diagnoses, treatments, and patient conditions. According to the Illinois Part 250 hospital licensing requirements, under the section of medical records, an adequate and timely medical record is maintained for each patient.
Example of Health Policy for Hospitals to Follow
Title: Authentication policies to address paper and electronic records and documentation
Purpose: To distinguish and differentiate the contents, maintenance, and confidentiality of patients medical record information and a large number of entries made by healthcare providers.
Applicability: This policy applies to all the staff of the hospital that must follow every procedure stated.
Policy: Authentication of medical records and how the information is documented, i.e., the ink color, how information is corrected, signatures, time, and dates.
Procedure:
To create a defensible medical record of all the patients in the health care center. The patient records can be written in black ink and any changes or correctional made in red ink color.
Medical information is documented by the attending practitioner, i.e., a nurse who records patient history, attending physician, primary caregivers, and emergency contacts. The document is signed by both the nurse and the patient, and the date the document is signed is also recorded.
The designated record set (DRS) includes the financial and billing records, the enrollment date, claims, and health plans of the patents are recorded and stored in an electronic database that is accessible by an attending practitioner with the appropriate credentials or an insurance company covering the patient.
A signature is a crucial authentication factor and identifies the author or responsible party who takes account of the patient’s medical records. A signature is mandatory for practitioners denoting or gaining access to patients’ medical documents.
Recording shadow files are necessary as it contains copies only from the medical database that may be accessed for reference purposes but are not part of the legal, medical record.
Conclusively, the health policy should adhere to the state or nationally mandated guidelines. The hospital should come up with secure ways of keeping patient records and only allowing personnel with the appropriate authentication details access to patient files. The filing system of the patient records should have active patient materials in an alphabetical or number index for easier identification and the inactive patients’ files in different files or location.
