Policy and Procedure Manual
Information Management
(IM)
Table of Contents
IM- 01
IM-02
IM-03
IM-04
IM-05
IM-06
IM-07
IM-08
IM-09
IM-10
IM-11
IM-12
Request of Information from the Medical Record
Release and Disclosure of Confidential Information
Legal Requests and Subpoenas
Faxing and Emailing of Medical Information
Request to Inspect, Amend or Copy Protected Health Information
Compilation, Storage, Dissemination, and Destruction of Medical Record
Clinical Chart & Documentation
Resident Financial Charts
Password Use
Privacy, Confidentiality and Security of Records
Information Technology
Use of Abbreviations
POLICIES AND PROCEDURES
SUBJECT:
ISSUE DATE:
REQUEST OF INFORMATION FROM THE MEDICAL RECORD
June 30, 2002
REVIWEW/REVISION DATE: March 31, 2014
Page 1 of 2
POLICY NO. IM-01
PROGRAM: All
Policy: Original medical records, although kept for the benefit of the residents, are the property
of RHG and can only be removed in accordance with a court order.
Resident records and communication between staff members and residents shall be protected as
stated in Section 394.4615, F.S., 42 CFR, Part 2, HIPPA, 65E-5, F.A.C. and/or T.C.A. 33-3104(10).
RHG medical records contain information related to psychiatric, HIV, drug and alcohol, and
medical treatment and as such are considered super confidential.




Release of any information in the record is subject to state and federal laws.
Only the medical records representative(s) will process requests for release of
information to ensure that the release complies with applicable state and federal laws.
Information for the records (copies) can only be released with a valid authorization from
the resident or by court order.
Records will be available for use within the facility by all authorized resident care staff.
Procedure: All residents are given a Notice of Privacy Practices at admission. A signed copy
by the resident or guardian will remain on the chart acknowledging that the resident has read and
approved the Notice of Privacy Practices.
1. Authorizations- Prior to any use or disclosure health information an Authorization to
Release Confidential Information will be signed by resident or guardian. Authorizations
are valid if they contain all of the following information:
a. Name of the facility that is to release information.
b. Name of the person or institution and address the information is to be given.
c. Name of the resident.
d. Specific items to be released.
e. Expiration date of authorization
f. Right to revoke authorization
g. Statement of potential re-disclosure
h. Signature of resident or legal representative.
i. Signature of a witness who observed the signature.
j. Dated at the time of signature.
k. A legible photocopy of the authorization is acceptable.
2. Revocation- Revocation of authorizations is valid if they contain the following
information.
a. Name of the resident
b. Date of original consent.
c. Effect of revocation.
d. Effective date of revocation.
e. Signature of resident or legal representative.
POLICIES AND PROCEDURES
f.
Signature of a witness who observed the signature.
3. Exceptions- In a life threatening situation or when an individual’s condition or situation
precludes the possibility of obtaining written consent, Pasadena Villa may release
medical information to the medical personnel responsible for the individual’s care
without the individual’s authorization, if obtaining such authorization would cause any
excessive delay in delivering treatment to the individual.
4. Accounting- Residents have the right to request an accounting of certain instances when
protected health information about them is disclosed. The accounting will be in writing
within 60 days of receipt of the request and include the following
a. Date of disclosure
b. A brief description of the protected health information disclosed
c. A brief statement of the purpose of the disclosure that reasonably informs the
individual of the basis for the disclosure and/or a copy of the Authorization to
Release Confidential Information
d. Name and title of the person or officer responsible for receiving and processing
request of an accounting by individuals.
The first accounting to an individual in any 12 month period will be without charge. A
copy of the document will be retained with the chart.
5. Refusal to Honor Authorizations-RHG will refuse to honor a written authorization if
there is:
a. Reasonable doubt as to the identity of the person presenting the authorization, or
evidence that the person requesting the information is not the person named in
the authorization or refusal to offer reasonable proof identity.
b. Reason to suspect that the resident’s signature is not authentic.
c. Reason to question the current validity of an authorization because it is general in
nature and does not specifically identify the type of records to be released or the
specific item to be released.
d. The physician and/or Clinical Director documents that release of information is
detrimental to the resident.
e. The physician may dictate a report of the examination and treatment in lieu of
releasing copies of the record.
6. General Guidelines:
a. Only those portions of the record specifically requested will be released.
b. Written consent is not required by staff for use of the record for information for:
business office procedures, monitoring and evaluating quality of resident care,
reviewing work performance, official surveys for compliance and accreditation,
regulatory and licensing standards, or for educational purposes and/or approved
research programs which do not include the identity of the resident.
c. Requests from physicians who are attending the resident at the time of the
request will be honored.
d. Third party records will not be released.
e. All requests for records will be logged in the resident’s chart.
POLICIES AND PROCEDURES
SUBJECT:
RELEASE AND DISCLOSURE OF CONFIDENTIAL INFORMATION
ISSUE DATE:
June 30, 2002
REVIEWED/DREVISION DATE: March 31, 2014
Page 1 of 2
POLICY NO. IM-02
PROGRAM: All Programs
POLICY:It is the policy of RHG to take all reasonable steps to satisfy its legal or moral obligation for information of
a confidential nature, which is created or obtained through the daily operation of the Facility.
During the course of the delivery of health care and the conduct of business activities within the facility, a large
quantity of information, verbal and written, in the form of records and reports is created, accumulated, transmitted,
and/or retained. Some significant portion of this information is of a private, personal nature, is strictly business
oriented, or is of such nature that its disclosure might result in an adverse reflection upon the system or upon another
party. The indiscreet and/or untimely disclosure of such information, however innocently tendered, is a breach of trust
and is to be avoided. Special care is to be exercised in the dissemination, disclosure and release of such information
both within and without the facility.
CONFIDENTIAL INFORMATION- This term is construed to include resident information and medical records, all
information pertinent to employees and their employment records, business and financial information, and such other
information as may be determined for "official use" only.
PROCEDURE:
1.
The general rule is that such information will be transmitted or released only to those individuals or
organizations on an official need to know basis.
2.
The general rule in all instances will be applied consistent with any statutory or regulatory requirement(s), the
customary practices prevailing in the conduct of business activities and operations, the desirability to
cooperate and extend mutual courtesies to other parties and organizations, and the responsibility to provide a
service requested by employees or residents or to accommodate to their written instructions concerning the
dissemination and release of information personal to them.
3.
Resident information and medical records will be treated as required by law, customary practice and RHG
policy and procedures. The Compliance Manager should be consulted when these guidelines are not
sufficient.
4.
Information pertaining to employees, either individually or collectively, will be treated consistent with legal
requirements, policy and procedures of RHG and the expressed wishes of respective employees.
5.
Financial information will be administered in such a manner as to conform to legal requirements, RHG policy
and procedures and the customary practices in the community and industry.
6.
Other information deemed confidential will be administered consistent with the above guidelines in a prudent
manner by the responsible department supervisor.
POLICIES AND PROCEDURES
7.
The dissemination and release of information to the news media will be coordinated between the Governing
Board Members.
8.
The provisions of this directive are not intended to deny or delay the dissemination and release of confidential
information when such is necessary or desirable to the delivery of health care, the conduct of business, and to
other operational facets of the organization.
9.
The removal and disclosure of all protected resident information will be permitted by the assigned
psychotherapist if a current resident or the Compliance Manager if a discharged resident. All disclosures will
be logged in the Log of PHI.
POLICIES AND PROCEDURES
SUBJECT:
LEGAL REQUESTS AND SUBPOENAS
Page 1 of 1
ISSUE DATE: December 1, 2011
Policy No: IM-03
REVIEWED/REVISED DATE: March 31, 2014
PROGRAM: All
POLICY:
When legal requests and documents are received, it is the policy of RHG to handle these matters
efficiently and professionally. All requests will be review and responded to by upper
management.
PROCEDURE:
1.
Document requests, civil subpoenas and garnishments (and any other similar requests
where it does not appear that RHG is a target or potential defendant) will be forwarded
immediately to the Compliance Officer and/or Executive Administrator.
2.
If it is unclear whether RHG may be a target or potential defendant, requests will be
forwarded to the Executive Administrator and/or Governing Board immediately for
review and response.
3.
If it is obvious that RHG is a target, defendant or potential defendant (notice of intent
letter, grand jury subpoena, summons, and complain or civil warrant). Requests will be
forwarded to the Administrator and/or Governing Board immediately for legal counsel
and response. A confidential and separate file will be maintained for communication
with counsel.
4.
Requests and communication with counsel will not be documented in the medical record.
POLICIES AND PROCEDURES
SUBJECT: FAXING AND EMAILING OF MEDICAL INFORMATION
ISSUE DATE: June 30, 2002
REVIEWED/REVISION DATE: March 31, 2014
Page1of2
POLICY NO. IM-04
PROGRAM: All Programs
POLICY:
It is the policy of RHG to limit the faxing of medical information concerning residents at
the facility. Faxing will be done only in accordance with this policy and will be accompanied by a fax
cover letter with company letterhead.
The faxing of resident information is a valuable technology for immediately meeting resident care needs
for information, particularly in the event of a medical emergency. However, the faxing of resident
information places the facility at risk for breach of confidentiality due to lack of control over the recipient
of the information, and due to the element of human error involved in misdialing a number or sending the
information to a wrong number.
PROCEDURE:
1.
Resident medical information will be transmitted to outside facilities by fax only for urgent and
immediate treatment needs when the mail delivery or overnight mail copies will not serve, and
only as needed for resident encounter.
(NOTE: Information may be faxed to third party payors to maintain certification of treatment.)
2.
Faxing of medical information will not be used for routine release of information to insurance
companies, attorneys, or other health care entities for convenience.
3.
The Compliance Manager will determine when faxing is appropriate in questionable instances.
4.
A faxed authorization will be considered valid for release of information if it meets the
requirements of a valid consent form.
5.
Information will be faxed only to and from machines located in secure areas as determined by a
telephone call to the requestor prior to the faxing of information.
6.
The information will be faxed using a cover letter. If the receiver does not call to acknowledge
receipt, as directed by the cover letter, a follow-up call will be made to ensure the information
was received.
7.
If information is inadvertently sent to a wrong number (misdial, wrong number, etc.) An incident
report will be completed giving complete details of the error and will be submitted to the Risk
Manager.
POLICIES AND PROCEDURES
8.
If a fax is received in error, the sender will be notified that it has been received and the copies
will be shredded.
9.
In the event of a medical emergency when the resident is unable to sign the consent form,
information will be faxed only to a physician (using the above guidelines); the complete
circumstances of the faxing of the information will be documented and filed in the resident’s
medical record.
10.
Medical records will not be disseminated via email for any reason as Pasadena Villa does not
have a secure server.
11.
Cell phone text messages will not be used to communicate resident information or conduct
official company business as this is not a secure form of communication.
POLICIES AND PROCEDURES
SUBJECT: REQUEST TO AMEND or INSPECT PROTECTED HEALTH INFORMAITON
Page 1 of 1
ISSUE DATE: March 31, 2006
REVIEWED/REVISED DATE:
Policy No: IM -05
March 31, 2014
PROGRAM All Programs
POLICY:
RHG, in compliance with all state and federal regulations concerning protected health
information provides each current or former resident the right to inspect their record. Residents have the
right to request an amendment (clarification or challenge) to their medical/clinical file if they feel the
information is incorrect or inaccurate, in writing.
PROCEDURE:
Inspect/Copy: Residents should submit their request to Inspect or Copy to the Compliance Manager. The
Compliance Manager will review the request and provide a written response within 15 days.
Amendment: Residents should submit their request to Amend to the Compliance Manager. The
Compliance Manager will review the request or appoint an individual not involved in resident care to
review and provide a written response within 15 days. These requests for amendments and responses are
to be placed in the medical record. All denials will be reviewed by the Risk Manager within the week
with a response in 15 days.
POLICIES AND PROCEDURES
SUBJECT:
COMPILATION, STORAGE, DISSEMINATION and
DESTRUCTION of MEDICAL RECORDS
ISSUE DATE: June 30, 2002
REVIEWED/REVISION DATE: March 31, 2014
Page1of2
POLICY NO. IM-06
PROGRAM: All Programs
POLICY:
It is the policy of RHG to ensure the safety and confidentiality of resident medical records at
all times. The Compliance Manager will oversee the storage, request for copies and destruction of medical
records.
PROCEDURE:
1. All records of current residents are kept at the nurse’s station or internet based secure records system,
which will be accessible to authorized personnel only. The facility shall maintain a master filing
system, which includes a comprehensive record of each resident’s involvement in every aspect of the
program.
2. Any resident information delivered to the facility will be scanned immediately into the resident’s
electronic record. (Examples: laboratory reports, assessments from various referral sources,
consultations from outside sources, past records).
3. Any records created in paper format (after 2010) will be scanned into the electronic health record for
storage, labeled, verified and the paper then shredded.
4. Information is released only with an authorization except where stated in the Request for Information
from the Medical Record policy (IM-02). Requests for information will be forwarded to the
Compliance Manager; when satisfied, are placed in the resident record.
5. Paper medical records (records prior to 2010) are filed by their record number and maintained in a
locked medical records room with access limited to authorized personnel only. Electronic records are
maintained as “inactive” in the record database after discharge.
6. Resident paper records shall be maintained on-site for a minimum of seven (7) years from the date of
the last entry. After such time the facility may shred through a professional shredding company all
documents and records. Any records involved in a legal process against the organization initiated
prior to destruction, will not be destroyed. All intentional destruction of records will be at the
direction of the Compliance Manager at least annually.
7. Electronic records will be maintained on a HIPAA compliant electronic health record software
system. The electronic health record system will be password protected to protect against
unauthorized access, use and disclosure of health information.
8. Each employee will have a unique ID and password to access the record system with access limited
POLICIES AND PROCEDURES
to the individual’s role within the company. For security; employees are not to loan/borrow other’s
login.
9. Each author should “lock” their final entry to ensure privacy and accuracy of the medical record.
10. Dissemination of protected health information will only be permitted by the assigned
psychotherapist for current/active resident and the Compliance Manager for discharged residents.
Dissemination of records will be in accordance with RHG policies and procedures and applicable
state and federal laws. Information is to be released based on the minimum necessary to meet the
request.
11. RHG protects from unamortized access, use and disclosure of health information by limiting
access of each employee based on their assigned clinical responsibility. Access is set by the
Executive Administrator. Terminated employees are immediately inactivated in the electronic
medical record system.
12. RHG protects the integrity of health information against loss, damage, unauthorized alteration,
unintentional change and accidental destruction. The ability to alter, unlock and or delete records
is limited to the Executive Administrator, Compliance Manager, Clinical Services Manager and
Utilization Management Coordinator.
POLICIES AND PROCEDURES
SUBJECT:
CLINICAL CHARTING& DOCUMENTATION
Page 1 of 5
ISSUE DATE: June 30, 2002
REVIEWED/REVISION DATE: March 31, 2014
POLICY NO. IM-07
PROGRAM: All Programs
POLICY: It is the policy of RHG to maintain a record on each resident, which is located on a secure HIPPA
compliant internet based database. The resident record contains past and current data regarding the resident and
his/her progress throughout their treatment at the facility. The Medical Record will be maintained by clinical staff
under the following general guidelines for documentation and consists of reports listed in this policy, which must
be completed in accordance with the time frames and approved formats specified in this policy. Any proposed
changes in any medical record report must be reviewed and approved by the Management Team and forwarded to
the Governing Board for their concurrence.
PROCEDURE:
General Guidelines:
1.
All medical records are the property of RHG and may only be removed from the facility’s premises by
subpoena, court order or statute.
2.
The medical record shall be confidential, current and accurate.
3.
All entries in the medical record must be complete and locked by the author.
4.
Progress notes shall include all significant clinical information or events pertaining to the resident.
5.
No abbreviations may be used when entering the diagnosis in the medical record.
6.
Correction of errors in the medical record shall be made in the following manner:
Written: A line shall be drawn through the erroneous statement, initialed, dated and the correct statement
written below.
Electronic/locked: A second entry “append note” and with the correct information will be written.
7.
Only those abbreviations on the Approved Abbreviation List for the facility may be used in the medical
record but should be limited to Physician’s Orders.
8.
Only licensed nurses and physicians will make entries relative to nursing issues (such as medication and
their effects, treatment, and assessment of medical/physical complaints.)
9.
All significant events will be charted in individual charts and include but not limited to:
A.
Psychotic behaviors
B.
Mood swings
C.
Verbal threats
D.
Sexual behavior
POLICIES AND PROCEDURES
E.
F.
G.
Aggression toward self or others
Suicidal ideation or attempts
Emergency phone calls:
H.
I.
J.
K.
J.
L.
M.
N.
(1)
Police
(2)
Rescue
(3)
Physician
(4)
Ambulance
(5)
Supervisor
Change in eating and/or sleeping habits
Walk Offs
Visits from significant others and how tolerated
Physical and somatic complaints
Significant change in mental status
Hospitalization
Any other event resulting in unusual incident reports
Abnormal lab values and action taken
Content of Medical Record
Physical Examination: To be initiated on each new resident within 24 hours of admission by the off campus
community provider physician, if the resident does not come for admission with a physical examination not older than
60 days old. The physical examination shall be completed within thirty days of admission. The physical examination
will include, at a minimum: (a) a medical history, including responses to medication, physical diseases and physical
handicaps; (b) the date of the last physical examination; (c) a description of physical status, including diagnosis and
any functional limitation; (d) recommendations for care, including medication, diet; and (e) to the extent possible, a
determination of the presence of a communicable disease.
Consultation: Residents may be referred to outside providers to attend to additional medical, dental and nutritional
needs. Reports (off campus community providers) are to be filed immediately upon the resident's return from the
consulting physician's appointment.
Initial Treatment Plan – Completed at Admission with preliminary diagnosis and updated during the assessment
process as needed with MD changes to diagnosis.
Risk Assessment – Completed at admission and as needed to manage resident risk.
Assessments and Re-assessments – Assessments of the resident will be completed by the appropriate staff and in time
frames outlined in specific assessment policies.
Master Treatment Plan- to be completed/coordinated within thirty (30) days of admission by the assigned therapist
(nursing staff when appropriate) based on information from the assessments in the approved format. The Master Plan
of Care must contain:
a.
b.
Discharge Criteria
Treatment goals based on the assessments that reflect the resident’s own words.
POLICIES AND PROCEDURES
c.
d.
e.
Objectives stated in incremental steps to achieve the treatment goals, sufficiently specific to assess
the progress and a projected date for achievement.
Interventions to meet the treatment goals to include the person responsible for the intervention and
frequency of the intervention.
Discharge Plan.
(Note: The psychotherapist is responsible for informing the parents or guardians of the resident’s treatment
progress, reviewing the treatment plan and all updates with them)
Psychotherapy Weekly summary - to be written within seventy-two (72) hours after the final weekly session by the
Psychotherapist and will include information pertaining to individual, group and/or family sessions
Psychiatric Evaluation must include presenting compliant, history of treatment, current mental status, the resident’s
diagnosis, current medications and any changes to diagnosis or medication and the rationale in addition to other
diagnostic data.
Physician's Progress Notes – To be entered within three (3) days after the weekly session of resident’s treatment and
progress in all clinical areas.
Physician Orders – orders are to be written by the physician subject to the following guidelines:
1.
Telephone orders are acceptable only when the following stipulations are met:
a.
b.
The situation is an Emergency and/or the situation is URGENT.
The medical staff member dictates the order(s) to a Registered Nurse who writes the
dictated order(s) in the medical.
c.
The medical staff member must sign such orders within 7 days.
Nursing Assessment – to be completed at admission providing a clinical picture of the history and current health
of the resident including a review of systems, vitals, pain assessment and withdrawal symptoms.
Nursing Progress Notes - to be completed weekly, summarizing the resident’s treatment. In addition,
interdisciplinary progress notes are to be written as necessary for critical events arising during resident’s stay.
Medication or treatment shall be administered only upon written and signed orders of a practitioner acting within
the scope of his/her license as prescribed.
Medication Administration Records – will include date, time, medication given, dosage as well as over the counter
medication. The MAR will be filed in the medical record at the end of each month.
Discharge Summary - to be completed at the time of discharge of the resident. The psychotherapist and nurse are
responsible for coordinating the completion of the discharge summary.
Completion of the discharged record - It is the responsibility of all members of the clinical staff to insure that the
discharged medical record is completed, including signatures at discharge.
POLICIES AND PROCEDURES
Documentation will be divided by discipline as follows:
Admissions staff or designee:
Emergency Contact Sheet
Resident Orientation
Notice of Privacy Practices
Resident Rights
Resident Responsibilities
Consent for Treatment
Equine Consent (TN only)
Authorization for Release of Information
Admission
Admission
Admission
Admission
Admission
Admission
Admission
Admission
Nurses:
Vital Signs and Weights
TB form
Nursing Assessment
Nursing Re Assessment
Weekly Nursing Summary
MAR
Controlled Drug Count
Master Treatment Plan
Pain Assessment
Abnormal Involuntary Movement Scale
Crisis Prevention Note
Drug Destruction Form
Discharge Summary
Medication Reconciliation Form
Weekly
Admission
Admission
Every 6 months, change of level of care, PRN
Weekly
Daily
Daily
PRN
PRN
PRN
PRN
PRN
At Discharge
At Admission and Discharge
Physicians:
Psychiatric Admission Assessment
Psychiatric Progress Report
Physicians Orders
Abnormal Involuntary Movement Scale
Discharge Summary
within 5 days of Admission
Weekly
PRN
PRN
At Discharge
Psychotherapists/Counseling interns (including Clinical Services Managers):
Initial Treatment Plan
At Admission
Risk Assessment
At Admission, PRN
Psychosocial History
72 hours
Psychosocial Re Assessment
Every 6 months, change of level of care, PRN
Master Treatment Plan
30 days after admission, every 30 days
Every 90 days for Case Management
Referral Communication Log
Weekly, PRN
Group Notes
Daily on each group completed
Family Contact Note
Weekly
Psychotherapy Weekly Summary
Weekly
POLICIES AND PROCEDURES
Case Management Notes
Transition Plan
Therapeutic Leave of Absence Plan
Discharge Summary
Transfer Log/Communication Record
Crisis Prevention Note
Behavior Contracts
Weekly for Case Management
PRN, change of level of care
PRN
At Discharge
PRN, change of location
PRN
PRN
Recreation and Adjunctive Therapists:
Recreation Therapy Assessment
Recreation Therapy Re-Assessment
Recreation Therapy Group Note
3 days
Every 6 months, change of level of care, PRN
Daily on each group completed
Residential Care Coordinators:
Property Inventory (TN only)
Interdisciplinary Progress Note
Visuals/Q 15 minute Checks
Crisis Prevention Note
Admission
Daily, on day and swing shift
PRN
PRN
Case Managers:
Psychosocial History
Psychosocial Re Assessment
Risk Assessment
Action Plan
Action Plan Review
TLLC Weekly Summary
Life Skills Management Note
TLLC Discharge Plan
Transition Plan
Transfer Log/Communication Record
Crisis Prevention Note
Behavior Contracts
Referral Communication Log
72 hours
Every 6 months, change of level of care, PRN
72 hours, PRN
30 days
Every 30 days
Weekly
Weekly
At Discharge
PRN, change of level of care
PRN, change of location
PRN
PRN
Weekly, PRN
Outside Providers:
History and Physical
Labs
30 days from admit or 60 days prior to admit
PRN
Documentation that is not completed in a timely manner will be addressed with the Compliance Manager and
direct supervisor and may subject to disciplinary process.
POLICIES AND PROCEDURES
SUBJECT: RESIDENT FINANCIAL CHART
ISSUE DATE: May 1, 2013
REVIEWED/REVISION DATE: March 31, 2014
PAGES 1 of 1
POLICY NO.: IM-08
PROGRAM. All Programs
POLICY: It is the policy of RHG to keep a financial chart of invoices and payments for each resident that
accesses services. This chart may include monthly invoices billed to the financial guarantor, a signed
financial contract, and Notice of Insurance Billing Practices. The payment source will be maintained in the
financial file until discharge and then removed and shredded prior to storage.
PROCEDURES:
1. The Client Services Representative will coordinate the payment for services and the signing of the
financial contract with all guarantors of services through RHG.
2. All current residents will have a financial chart maintained by the Client Services Representative in a
locked filing cabinet and locked office. Access to the office is limited to the business office staff.
Access to the filing cabinet is limited to the Client Services Representative only.
3. The financial contract will be scanned and entered into the electronic health record of the resident by
the Client Services Representative.
4. No payment information will be used for resident ancillary expenses, spending money, cash or
outside appointments.
5. Financial files of discharged residents will be stored in the locked medical records room and
destroyed after 7 years; at the direction of the Compliance Manager and in accordance with local and
state laws concerning financial records.
POLICIES AND PROCEDURES
SUBJECT:
PASSWORD USE
ISSUE DATE:
April 12, 2012
REVISION DATE:
March 31, 2014
Page 1 of 1
POLICY NO. IM-09
PROGRAM: ALL
Policy:
Staff will be assigned user names and passwords for electronic systems that house confidential and
private information on residents, employees and for staff training and development. Staff is responsible
for any actions that are conducted using these accounts. The medical record will be maintained by
clinical staff under the following general guidelines for documentation and consists of reports listed in
this policy, which must be completed in accordance with the time frames and approved formats specified
in this policy. Any proposed changes in any medical record must be reviewed and approved by the
Management Team and forwarded to the Governing Board for their concurrence.
Procedures:
General Guidelines:
1. Staff may only use password protected computers for documentation and email associated with
RHG.
2. Staff may only use logins assigned by the facility to access controlled databases. Access is limited
and set by the appropriate department manager.
3. Staff may not share or loan logins and/or passwords to other employees.
4. Staff may not use another person’s login and/or password.
5. Staff may not allow anyone who does not have an authorized login to access any electronic database
content or copy materials.
6. Staff will not allow any family members, friends, former employees, classmates and/or colleagues to
use accounts, take courses or exams on their behalf.
7. Acts or the condoning of acts which achieve or attempt to achieve the unauthorized use or copying of
data is prohibited. Examples of unauthorized use or copying include attempts to alter systems,
attempts to circumvent systems protections features, attempts to alter or destroy course and test data,
attempts of unauthorized access or copying of course and test data or software, attempts to release
data or software that has not been previously authorized.
POLICIES AND PROCEDURES
SUBJECT: PRIVACY, CONFIDENTIALITY AND SECURITY OF RECORDS
ISSUE DATE: June 30, 2002
REVIEWED/REVISION DATE: March 31, 2014
PAGES 1 of 1
POLICY NO.: IM-10
PROGRAM. All Programs
POLICY:
It is the policy of RHG to assure that the confidentiality of residents’ identities shall be
protected in all Quality Assurance/Medical Records activities in accordance with Federal HIPAA regulations.
Health information will be kept secure and use limited.
PROCEDURES:
1.
All records shall be subject to the same confidentiality procedures as applies to any other
protected document.
2.
Staff and interns will be required to attend an annual inservice on HIPAA laws and agency
policies regarding resident confidentiality.
3.
Staff will be required to have a HIPAA disclaimer on all clinical emails and faxes from the
program. Fax numbers will be verified prior to transmission.
4.
Staff will be assigned a computer password to protect information when working at a computer
station. Staff will sign off prior to leaving the area.
5.
Staff will use the clean desk protocol and clear the desk area of files and paperwork prior to
leaving the area unattended by staff.
6.
Staff will not share passwords or logins to electronic health systems as each user has assigned
access to areas of the record that pertain to their assigned role.
7.
Verbal communications regarding residents will take place in offices or in a tone of voice that
protects resident information from other residents and visitors.
8.
Visitors to RHG will be required to sign a Notice of Confidentiality, stating that they cannot
release the names or identities of any resident at the facility for any reason.
9.
RHG will not post signage on the outside of the building which identifies the facility as a
treatment facility, nor will there be signage on any company vehicle which could compromise
resident confidentiality.
Residents will be present with RHG’s Notice of Privacy Practices at admission. Resident health
information will only be used and disclosed for purposes permitted by law and regulation as
outlined by this notice.
10.
POLICIES AND PROCEDURES
SUBJECT: INFORMATION TECHNOLOGY
ISSUE DATE: May 1, 2013
REVIEWED/REVISION DATE: March 31, 2014
PAGES 1 of 1
POLICY NO.: IM-11
PROGRAM. All Programs
POLICY: It is the policy of RHG to have a plan to manage interruptions to its electronic information
processes and to restore use as soon as possible.
PROCEDURES:
1. RHG will maintain and electronic health record on each resident that is maintained on an encryption
secure internet based system.
2. Staff will be notified as soon as possible for any scheduled interruptions in the electronic health
record system with date and time duration of the interruption.
3. During scheduled and unscheduled interruptions in the electronic health record, documentation will
continue as defined by the Charting and Documentation Policy (IM-07) on password protected
computers. Once use is restored to the electronic health record, the author will copy the information
into the record and denote “LATE ENTRY” as needed.
4. All records created during interruptions will be verified in the electronic health record before being
deleted from the computer. Staff will transfer and delete protected health information as soon as
possible after restoration.
5. Staff will not transmit or create confidential information, pictures or recording about or including
residents via cell phone text, web camera, social networking or other forms of electronic social
media.
6. The Referrals and Admissions Department will be responsible for the content of all website, print
material and social media presence. Website content will not include protected health information or
photographs of any current, former or potential resident. All content will be preapproved by the
Referral Relations Manager and monitored by the Referral and Admissions Assistant daily.
7. Access to the company website and social media pages will be limited to the Referral and Admissions
department, monitored daily and inappropriate content deleted.
8. Accounts receivable and accounts payable will be maintained on encryption secure internet based
systems and accessed by password protected computers.
9. Interruptions in internet service may result in manual checks for accounts payable if business services
will be interrupted. Non-emergent accounts payable and accounts receivable will process any
POLICIES AND PROCEDURES
payments when service is restored.
POLICIES AND PROCEDURES
SUBJECT: USE of ABBREVIATIONS
ISSUE DATE: November 15, 2013
REVIEWED/REVISION DATE: March 31, 2014
PAGES 1 of 9
POLICY NO.: IM-12
PROGRAM. All Programs
POLICY: It is the policy of RHG to identify acceptable abbreviations for use in the medical record.
Abbreviation use is discouraged as a form of daily documentation due to the increase in medical errors
associated with abbreviations. Abbreviations are not to be used in Treatment Plans, Assessments and
Discharge Summaries.
PROCEDURES:
If staff uses abbreviations in clinical charting, below are the approved lists of acceptable abbreviations to be
use.
Abbreviation a AA AB abn a.c. ACLS ACSM act ad.lib. ADD ADHD ADL AFA AFBS AH a.m. AMA AMI AMS amt. approx. appt. Meaning After Alcoholics Anonymous Abortion Abnormal Before meals Advanced cardiac life support Assistant Clinical Services Manager Activity As desired Attention Deficit Disorder Attention Deficit Hyperactivity Disorder Activities of Daily Living Arm, forearm A‐fordable Billing Solutions Auditory Hallucinations Before noon Against Medical Advice Acute myocardial infarction Altered mental status Amount Approximately Appointment POLICIES AND PROCEDURES
ARNP ASAP AU BID BM BS bs Ca cal. cap CBR CBT CD CDC chg ck cl cm. CM C/O conf. cont. cont'd CP CPI CPR CRH CSM C‐Section CV CVA CXR DBP DBT D&C D/C DDS Advanced Registered Nurse Practitioner As soon as possible Both ears Twice a day Bowel movement Breath sounds bowel sounds Calcium Calorie Capsule Complete bed rest Cognitive Behavioral Therapy Chemical Dependency Center for Disease Control Change check Clear Centimeter Case Manager Complain of Conference Continue Continued Chest pain Crisis Prevention Intervention Cardiopulmonary resuscitation Community Residential Home Clinical Services Manager Cesarean section Cardiovascular Cerebrovascular accident Chest X‐ray Diastolic Blood pressure Dialectical Behavioral Therapy Dialation and curettage Discontinue, Discharge Doctor of Dental surgery POLICIES AND PROCEDURES
D.E.A. del. Dept/dept detox Diff Dig DKA DM DNR D.O. D/O DOA DOB DOD Dr. dsg DT DVT Dx ECG,EKG ECT ED ed EEG EENT e.g. EMDR EMS EMT E.P.S ex F fax FB FBS FDA FHx Drug Enforcement Agency Delusions Department Detoxification Differential count Digoxin Diabetic Ketoacidosis Diabetes Mellitus Do not resuscitate Doctor of Osteopathy Disorder Date of Admission Date of Birth Date of Discharge Doctor/Physician Dressing Day Treatment Deep vein thrombosis Diagnosis Electrocardiogram Electroconvulive therapy Emergency department education Electroencephalogram eyes, ears, nose, throat Example Eye Movement and Desensitization and Reprocessing Emergency Medcial System Emergency Medical Technician Extra‐pyramidal side effect Exercise Female Facsimile Foreign body Fasting Blood Sugar Federal Drug Administration Family history POLICIES AND PROCEDURES
fl Freq. Fri. F/U FX GAF gal. gm/GM gtt GYN H&H H&P HA HI HR h.s. HTN Hx i.e. IM IN incont inf int. IO IOP irreg JCAHO K kg/KG L Lab Lap. lat. lax. lb./LB LCSW Fluide Frequency Friday Follow Up Fracture Global Assessment of Functioning Gallon gram Drop Gynecology Hemoglobin and hematocrit History and physical Headache Homicidal ideations Heart rate At Bedtime Hypertension History For example Intramuscular Inches Incontinent Inferior Internal Intraocular Intensive Outpatient Program Irregular Joint Commission on Accreditation of Healthcare Organization Potassium kilogram Left Laboratory Laparotomy Lateral Laxative Pounds Licensed Clinical Social Worker POLICIES AND PROCEDURES
LD lg. liq LL LMFT LMHC LMHCI LPC LOA LOC LOS LPN M max mcg MAR M.D./MD MDD Meds Mg mg/MG MI misc ml/ML mm/MM MOM MRI MSW MVA MVI na N.A. N/A neg nml NIDDM NKA Learning Disability Large Liquid Left Leg Licensed Marriage and Family Therapist Licensed Mental Health Counselor Licensed Mental Health Counseling Intern Licensed Professional Counselor Leave of Absence Level of Care Length of Stay Licensed Pratical Nurse Male Maximum Microgram Medication administration record Doctor of Medicine Major Depressive Disorder Medication Magnesium Milligram Myocardial infraction Miscellaneous Milliter Millimeter Milk of Magnesia Magnetic resonance imaging Master of Social Work Motor vehicle accident Multivitamin Sodium Narcotics Anonymous Not Applicable Negative Normal Non‐insulin dependent diabetes millitus No known allergies POLICIES AND PROCEDURES
NPO Nsg NSR NSAID NTG N/V O2 OB OCD oint. o.k. OP Oriented x3 O.S. OTC O.U. p P.A. p.c. P/E PERLA PHP p.m. Po/PO pos. Post‐Op prn/PRN Pre‐op Pt. PT/NR PV Px q q2*h q.a.m. q.d. q.h. Nothing per os Nursing Normal sinus rhythm Non‐steroidal anti‐inflammatory drug Nitroglycerin Nausea and Vomiting Oxygen Obstetrics Obsessive Compulsive Disorder Ointmeent Okay Outpatient/Outpatient Program Orientated to person, place, time Left eye Over the counter Both eyes After Physician's assistant After meals Physical examination Pupils equal & reactive to light Partial Hospitalization Program Afternoon By mouth Positive Postoperative As necessary Preoperative Patient Prothrombintime Pasadena Villa Prognosis Every Every 2 hours (*3,4,…) Every morning Every day Every hour POLICIES AND PROCEDURES
q.h.s. q.i.d. q.o.d. qt. PV R RBC RCC R.D. Rec Resp RHG RN R/O RR RTC r/t Rx Sat. SBP S.I. SML S/O SOB SQ Stat/STAT STD Sun. supp. SW Sx tab. TB tbsp. Thurs. TID TLLC Every night at bedtime Four times a day Every other day Quart Pasadena Villa Right Red blood cells Residential Care Coordinator Registered Dietician Recreational Respirations Renaissance Healthcare Group Registered Nurse Rule out Respiratory rate Residential Care Related to Prescription Saturday Systolic blood pressure Suicidal ideation Smoky Mountain Lodge Significant other Shortness of breath Subcutaneous At once Sexually transmitted disease Sunday suppository Social Worker Symptoms Tablet Tuberculosis Tablespoon Thursday Three times a day Transitional Living and Learning Center POLICIES AND PROCEDURES
T/O Tsp Tues. Tx UA UO UR UTI vc's VD V.O. V.S. WBC w/c w/o Wed. WNL W/Wt. X/x XR = < > ~ # @ % + ‐ ' " 2o 1x 2x Telephone order Teaspoon Tuesday Treatment Urinalysis Urine Output Utilization Review Urinary Tract Infection Verbal cues Venereal disease Verbal order Vital signs White blood count With Without Wednesday Within normal limits Weight Times, except X‐ray Equals Less than Greater than Approximately Number At once Percent/Percentage Positive/present Negative/absent Foot/feet Inches Secondary Once Twice POLICIES AND PROCEDURES