Types of Dispositions
- Discharged
- Admitted
- Transferred
Level 5 Billing for HPI, ROS, PMHx/SHx/FHx, PE
- HPI: 4 elements
- ROS: 10 elements or 2 with “all systems negative” box checked
- Past Hx: 2 elements
- PE: 8 elements (at least one finding in 8 different organ systems)
Common critical care diagnoses
- MI
- PE
- CHF
- CVA
- A-Fib w/ RVR
- PTX
- Appendicitis (w/ rupture)
- GI bleed
- Sepsis
- Severe AMS,
- Meningitis
- DKA
- Acute renal failure
- Severely abnormal vital signs
Common critical care procedures
- Intubation
- Chest tube
- Central line
- CPR
- Cardioversion
- CPAP/BiPAP
What does HIPAA stand for? What is it?
Health Insurance Portability and Accountability Act
- Body of laws designed to protect the private health information of patients
What does PHI stand for? What is it?
Protected Health Information
- ANY type of information that can be directly or indirectly tied to a particular patient or visit
How are you affected by HIPAA/PHI?
You are not allowed to save copies of medical records, email them, store them outside of the hospital, or save them to external devices (USB/flash-drives) unless instructed to do so by the physician you are working with and save info to hospital approved devices
**You may NEVER save/transfer PHI of any kind to your personal email, smartphone, or any non-hospital approved device
HIPAA Rules (8)
- If a pt is not assigned to your doctor, do not touch the chart
- There is always someone watching
- Never share your username or password
- No cell phones or pictures
- Your job does not belong on social media
- Do not store any PHI on non-approved systems
- Do not access family, friend, or your own medical record
- Ask yourself, “do I need to access this for my job?”
ScribeAmerica rules/regulations (10)
- Scribes cannot touch pts
- Beware of provider entrapment
- Remove yourself from unprofessional situations/conversations
- Follow the dress code
- You cannot enter the facility unless you have your badge and your own EHR login
- No cell phones at work
- Do not access family, friend, VIP’s or your own medical records
- Never share your password
- Do not post any work-related information on social media
- Report all incidents to ScribeAmerica management
What is HITECH?
Health Information Technology for Economic and Clinical Health Act
- Addition to HIPAA; addresses privacy/security issues related to electronic transmission of health information
- PHI cannot be transferred electronically without encryption
Examples of PHI
- Patient name
- Geographic subdivisions
- Telephone numbers
- Email addresses
- Fax numbers
- Health Plan beneficiary numbers
- SSNs
- Certificate/license numbers
- Healthcare record numbers
- Account numbers
- Dates (except years)
- Any unique number/code/characteristic that can be linked to an individual
