Q: We recently had a patient who was admitted with sepsis and the physician documented sepsis, a urinary tract infection (UTI) related to a chronic Foley catheter, and pneumonia. Can we report sepsis first instead of the complication code, or is the complication always first?
Q: Does the HIPAA Privacy Rule strictly prohibit the disclosure or request of an entire medical record? If not, does there need to be a case-by-case justification every time an entire record is disclosed?
Q: Would it be appropriate to query the provider for clarification if documentation for an orbital fracture doesn’t specify the location of the fracture and whether it is open or closed?
Q: I work for a small rural hospital, and we have a lot of budget limitations for technology upgrades. Can we allow clinical staff to use their personal cell phones and mobile devices to communicate with patients? If so, how can we keep our calls, email, and text messages HIPAA compliant?
