Question

Guidelines for documentation in a patient’s health record are published by several professional organizations and the federal government. The Centers for Medicare and Medicaid Services (CMS) issue their guidelines in a document called Conditions of Participation (CoP). Review Medicare’s Conditions of Participation (CoP) for hospital medical record services (482.24) on the Code of Federal Regulations website Instructions A patient has recently been discharged. Your job is to review their patient record to ensure it is complete compared to Standards C.4.i and C.4.vii of the Medicare Conditions of Participation (CoP).

Answer 1

In reviewing patient records against Medicare CoP, it's important to address how to balance treatment costs, enhance patient quality of life, and protect privacy. HIPAA requires strict confidentiality of patient records, while the ACA focuses on reducing healthcare costs through measures like the adoption of EMRs and containing administrative spending.

Step-by-step explanation:

When reviewing patient records against the Medicare Conditions of Participation (CoP) for hospital medical record services, it's crucial to ensure that documentation within health records addresses essential concerns. Three questions that one must consider in developing policies regarding health records include: How can we balance the costs of treatments and diagnoses while ensuring high patient quality of life? What measures are in place to mitigate risks to individual privacy? And, how do legal considerations, such as those required by the Health Insurance Portability and Accountability Act (HIPAA), impact these policies?

Under HIPAA, maintaining the confidentiality of patient records is mandatory, and any disclosure of information needs careful consideration. In terms of coverage, Medicare Part A helps cover certain hospital charges but also includes deductibles and copayments, with no cap on total incurred costs. To control healthcare costs, the Affordable Care Act (ACA) imposed regulations such as a cap on administrative expenses and an emphasis on the transition to electronic medical records (EMRs), which can enhance efficiency and reduce administrative overhead.

The sharing of digital records among healthcare providers is recommended as a means to improve healthcare quality and reduce costs. However, the challenge remains to uphold the privacy of electronic health records while facilitating this improved level of coordinated care.