For organizations that allow clinicians to carry forward clinical documentation in electronic records, auditing its proper use is key to ensuring document integrity. Copying clinical documentation poses both clinical and compliance risk. The feature “Auditing Copy and Paste” offers guidance in creating a solid audit plan.

The story is adapted from the broader AHIMA resource “Copy Functionality Tool Kit.” It offers sample policies, testing activities, case scenarios, and questions organizations can ask when considering the use of copy and paste.

You’ll find a lot of other good practice resources on that page.

The January practice brief recommends resources for regulations and standards that apply to HIM practice in a range of settings. See the online version for links directly to the sources.

Get hip with HIPAA.

That’s just one of the taglines attached to Sharp Healthcare’s HIPAA education modules. Photos from the age of hip—the late 1960s and early 1970s—permeate the online HIPAA training modules. Musicians Jimi Hendrix and Bob Dylan and era-TV icons like the Get Smart cast mingle with privacy requirements and confidentiality factoids.

The hip-themed training is just one theme in a series of HIPAA privacy, security, and confidentiality training modules at the San Diego-based facility.

The incorporation of a new theme each year assures that Sharp’s staff of 12,000 employees learn more than how to fall asleep during training, says Paul Belton, RHIA, Sharp’s vice president of corporate compliance and creator of the unique training programs.

“All this is to just try and keep this fresh,” Belton says. “You come up with something that would be tasteful and flavorful to them to [avoid] the dry and boring education modules that are so typical.”

Keeping a facility’s HIPAA education program interesting year after year can be a challenge for privacy officers. They must develop interesting, comprehensive programs that stick for new employees as well as fresh refresher programs for current staff. (more…)

The clarifications continue over CMS’s approach to signature stamps. This past July CMS issued a clarification that stamps were not permissable on any medical record. Now a new clarification advises that some payers do not accept stamps but the Conditions of Participation do not prohibit them.

In the latest memorandum, dated October 24, CMS writes that the Conditions of Participation:

“do not prohibit the use of rubber stamps in a hospital setting, when properly controlled, for authentication of medical record entries. However, as a point of information for surveyors and providers, we are taking this opportunity to add an information-only statement to the interpretive guidance for §482.24(c)(1) to note that some payers, including Medicare, may not accept such stamps as sufficient documentation to support a claim for payment.”

“HIM and health IT are finding that the scope and responsibilities of individual job functions are increasingly crossing department domains,” write the authors of the practice brief “HIM and Health IT,” published in this month’s issue. They note a “universal need for alignment between the two disciplines to ensure that both business processes and technology are in place to advance successfully toward a fully functional [electronic health record].”

The brief explores that need for collaboration through three domains: confidentiality and security, data use and maintenance, and terminology asset management. Seven Web-only extras offer tools to help with that alignment. (more…)

UPDATE: CMS has since released new clarification stating that stamps are not prohibited under the Conditions of Participation, but that some payers may not accept them.

The Centers for Medicare and Medicaid Services no longer accepts signature stamps on any record. CMS attempted to clarify the scope of the ban this summer, but the message may not have percolated to all corners of the industry yet.

In July CMS stated that “stamped signatures are not acceptable on any medical record.” The prohibition applies to all providers and suppliers. Medicare will only accept “handwritten, electronic signatures or facsimiles of original written or electronic signatures.”

In spring CMS published a ban on signature stamps focused narrowly on the certification of terminal illness for hospice. The subsequent July notice explicitly included all medical records. (more…)

In Illinois healthcare organizations and trial lawyers are disagreeing over how much facilities may charge when fulfilling requests for health records that are stored electronically. Also at issue is whether facilities must provide their digital records in a digital format.

A state law lowering the copy fees for electronic documents went into effect January 1, 2008. The law, the result of negotiations that tempered reductions in earlier proposed legislation, is already being countered with a bill to create a higher flat rate for all copying, regardless of record format.

In part, the tug-of-war highlights the gap between expectations over health IT’s potential and the current reality on the ground. (more…)

A practice brief in the October issue offers a great introduction to enterprise content and record management and its application in healthcare organizations. The online version offers five web-only extras that help organizations begin planning. (more…)

In a September story in the print journal, HIM directors in New Orleans discussed the state of their departments three years after Hurricanes Katrina and Rita. One director described her operations as “not normal, but workable.” The same is true for the personal lives of many HIM staff at facilities throughout the region.

While water can be drained and medical records restored, the emotional scars of the hurricane remain vivid three years later. Lives were lost, possessions disintegrated, and families scattered across the country. As an HIM director, emotional understanding continues to be a requirement as HIM employees try to work and rebuild their lives at the same time. (more…)