HINF 3210Assignment 1
Health Record Documentation
Task
Audit a medical record for existence of relevant documentation.
Instructions
It is your responsibility as manager of a pediatric group to audit all medical records. You are tasked with
ensuring that all relevant documentation is present in the record.
Medical Record
Documentation
of Patient
Timothy
(information you
need to review
for this audit)
Office Note
8/15/2019
Timothy is a 10-month-old who presents today with bilateral earaches.
Timothy’s mother states that the child has been crying and pulling at his ears
for the last three days. She has also noticed a mild fever. Otoscopic
examination revealed bulging tympanic membranes indicative of fluid buildup. Amoxicillin prescribed for ear infection. Script e-faxed to pharmacy. Time
spent on encounter: 11 minutes.
CPT E/M Code for Visit 99202
Birth History
10/09/2018
Timothy had an uneventful, full-term, vaginal birth. Uncomplicated pregnancy,
natural childbirth. No forceps used in delivery. APGAR score at birth 9, repeat
APGAR 10.
Personal, social, and
11/10/2018
family history
Second child, one older sister who is 3 years old. Parents are married. Nonsmoking environment. No pets in the home. Will attend daycare after mother’s
maternity leave end in three months. Circumcised prior to discharge at birth.
Nutritional History
11/10/2018 Timothy is breastfed initially.
12/13/2018 Breastfeeding continues.
2/16/2019 Breastfeeding continues.
4/18/2019 Cereal has been introduced into diet, rice.
Office Note
Office Note
Office Note
Office Note
Medications
Activity
7/15/2019 Infant eats rice and oatmeal cereal, variety of fruits. No reactions
noted to new foods.
11/10/2018
Well-child visit. No problems. Child thriving. Growth appropriate.
12/13/2018
Well-child visit. No problems. Growth appropriate. First set of vaccines
administered.
2/16/2019
Well-child visit. No problems. Growth appropriate. Developmental milestones
met. Second set of vaccines administered.
4/18/2019
Well-child visit. No problems. Growth appropriate. Developmental milestones
met. Third set of vaccines administered.
8/15/2019 Amoxicillin BID for 10 Days
Using the checklist that follows, determine if all relevant documentation, including discharge status, is
present in the record. (Place descriptive comments in the blank cell.) Submit this table to the
assignment tool in D2L.
o Office note – well-child or medical
issue
o Birth history
o Nutritional history
o Personal, social, and family history
o Growth and development record
o Immunizations
o Medications
o Discharge status
Resource: Brickner, M.R. 2020. Health Record Content and Documentation. Chapter 4 in Health Information Management
Technology: An Applied Approach, 6th ed. N.B. Sayles and L. Gordon, eds. Chicago: AHIMA.
Rubric: The assignment will be graded based on the following scale. A total of 25 points are available.
Activity
Graded Items
Items submitted by due date
Office note – well-child or medical issue
Birth history
Points Available
5
5
5
Nutritional history
5
Personal, social, and family history
5
Growth and development record
5
Immunizations
5
Medications
Discharge status
Assignment is grammatically correct, free of errors in
spelling and punctuation
Asmt1HINF3210Fa2023.acb/08092023
5
5
5
Points Received
9/29/2020
HINF 3210
Module 4
Chapter 11
Data Privacy, Confidentiality, and
Security
ahima.org
ahima.org
© 2020 AHIMA
Protecting Patient Information
• Privacy
• Confidentiality
• Security
ahima.org
© 2020 AHIMA
Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
• Ensures health insurance portability
• Establishes standards for electronic claims and
national identifiers
• Protects against fraud and abuse
• Assures the privacy and security of protected
health information (PHI)
ahima.org
© 2020 AHIMA
1
9/29/2020
Title II: HIPAA Administrative Simplification
• Privacy Rule
• Assures individuals’ health information is properly
protected while allowing for quality care
• Security Rule
• Specifies administrative, technical, and physical security
procedures for covered entities to assure the
confidentiality, integrity, and availability of electronic
PHI
• Breach Notification Rule
• Creates a process for covered entities and business
associates to investigate and evaluate if a breach
occurred for an unauthorized use or disclosure of PHI
ahima.org
© 2020 AHIMA
Privacy Rule
• Uses and disclosures of PHI
• Minimum necessary
• Business associate agreements
• Notice of privacy practices
• Patients’ rights
• Request privacy protections
• Access their health information
• Request amendments
• Receive an accounting of disclosures
• Administrative requirements
ahima.org
© 2020 AHIMA
Security Rule
• Administrative
safeguards
• Physical safeguards
• Technical safeguards
• Organizational
safeguards
• Required vs. addressable
standards
ahima.org
© 2020 AHIMA
2
9/29/2020
Breach Notification Rule
• Unauthorized uses and disclosures of PHI at any
time may be considered a breach
• Requires covered entities and business associates
to investigate/evaluate if a breach occurred using
specific guidelines/protocols
• Risk assessment
• Reporting
• >500 patients
•
Order an Essay Now & Get These Features For Free:
Turnitin Report
Formatting
Title Page
Citation
Outline
