Undocumented policies and procedures are among the top five stumbling blocks to HIPAA compliance that Chris Apgar, CISSP, finds when he audits healthcare organizations.
Over the course of the past 30 years in the HIM field, I have observed much trial and error on the part of HIM managers who have been pioneers in the EHR journey.
Q A fax containing PHI is sent to an incorrect fax number. Did the covered entity (CE) or business associate (BA) violate HIPAA? Must the patient disclosure accounting record include this incident?
Sometimes the best care a patient can receive in the ED is to not be treated there at all. They can often have treatment needs and do received meds, but that does not necessarily entail an admission.
It's a scenario that plays out at hospitals across thecountry each day. A Medicare patient is scheduled for a procedure typically performed on an outpatient basis. But the patient has a number of preexisting health conditions, such as chronic obstructive pulmonary disease or diabetes, which are going to make the surgery and recovery more complicated.
