Failure to document the chart at all during a critical time is a breach of standard of care and documentation standards
Correction must be completed by the care provider within 60 days of the request
Both original and revised documentation must be retained as part of the record
Incorrect information should be deleted and replaced with the correct information.
Access whether further consultation is necessary and whether further legal processes may apply if the disclosure is required by law
Verify the identity of the requesting party
Ensure that the written consent form (if any) is filed on the individual’s health record, or that documentation is included providing the date of consent, the information provided and the date of disclosure
Verify that the consent form was dated less than 90 days ago
Electronic Service Provider
Health Information Network Provider
Documentation should be true, complete, clear, concise, and legible.
Documentation should include the date and time when the entry was made.
Documentation should be authenticated by the person who prepared it.
Documentation should take place within an hour of the event that is being recorded.
Independent medical examination reports.
Reports to government ministries.
Ask Dr. Brown to provide a consent form from Amy
Provide the records to Dr. Brown only if he is on your medical staff
Provide the records to Dr. Brown since he is treating the patient
Refuse access to the records
No consent is needed for emergency care
Remove the incident report and send it to the patient.
Tell the employee to leave the report in the record.
Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record.
Refer this record to the Risk Manager for further review and removal of the incident report.
Invasion of privacy.
Violation of security of person
Intellectual property rights
Accountability and governance
Mary is not required to release the extra documentation because the facility has the right to interpret a request and apply the minimum standard rule.
Mary is required to release the extra documentation because the requestor knows what is needed.
Mary is required to release the extra documentation because, in the customer service program for the facility, the customer is always right.
Mary is not required to release the additional information because her administrator agrees with her
1 and 2 only
1 and 3 only
2 and 3 only
2 and 4 only
Electronic signatures are not acceptable in many health care facilities
Evidence cannot be provided that the physician reviewed and approved each report
It is too easy to delegate use of computer passwords
Tampering too often occurs with this method of authentication
Acknowledgement of having received patient’s rights information
Consent to release information
Consent to undergo treatment
Try to get it signed, and if not, to document the action taken.
Keep trying to get the document signed until you succeed, even if you must go to the patient's hotline.
File the blank form in the chart.
Information system activity review.
Workforce clearance procedure.
Information access management.
How the situation might be averted in the future.
The principles and values at stake.
The ethical question.
CHIMA Code of Ethics.
Staff members union.
Human resources department.
Identify the facts.
Define the ethical question.
Identify the principles and values at stake.
Identify how the situation might be averted in the future.
CHIMA Board of Directors.
CHIMA Chief Executive Officer.
CHIMA Vice President of Professional Practice.
Professional Ethics Committee.
Expulsion and revocation of credential
Suspension of membership and credential
Will the corrective actions result in the respondent's being more aware of and complaint with appropriate ethical practice principles then he or she was before the infraction?
Why is the person limiting the information to be released?
What is the rationale for the specific corrective action(s) in relation to the ethics violations?
What is the rationale for the sanction(s)?
Dyadic Relationship Theory
Perform a 100% review of one of the employees' work each day.
Review a sample of each employee's work annually.
Review a random sample of each employee's work monthly.
Have each employee check each other's work and report any problems to the supervisor.
Serial unit numbering
Unit numbering system
Family numbering system
Serial numbering system
If a task is divided among employees disproportionately.
The solution to a specific problem area.
If the skills of each employee are utilized appropriately.
The appropriate method of work division.
Leaving the policy as written in the manual.
Contacting the hospital attorney to decide what action to take.
Enforcing tile existing policy.
Revising the policy appropriately and documenting the date of the change
Capital budget and the finance budget
Capital budget and the operational or revenue and expense budget
Profit and loss budget and the finance budget
Finance budget and the revenue and expense budget
Work distribution chart.
Flow process chart.
Project scope, resources needed, and amount of time required
Project scope, resources needed, and developing the solution
Resources needed, amount of time required, and preparing supporting documentation for the system chosen
Amount of time required, alternative analysis, and implementation review
Offer leadership and a proactive, innovative approach to advancements in health information management practices.
Perform duties diligently and offer only those services for which one is qualified.
Conduct oneself in an ethical manner consistent with the values of the Canadian College of Health Information Management and report any unethical practices to the privacy commissioner.
Support and mentor students, peers and colleagues to develop and strengthen the workforce and profession.
Do nothing because the coding area is extremely productive.
Discuss the problem with the CFO.
Discuss the matter directly with the coder and instruct him to review the entire record for correct assignment of codes
Discuss your concerns with the supervisor of coding and direct her to address this issue immediately.
Written warning and reprimand
Meeting with the supervisor of her supervisor
Cause and effect diagram
Communication and consultation.
Monitoring and review.
The "No" Zone
The "Go" Zone
Offer a prize to the employee who locates the requested records first
Review and possibly reengineer the retrieval process to decrease retrieval time
Allow the requesters to retrieve the record themselves
Increase file area staff to include one additional file clerk devoted to pulling records for the emergency room
Both records are combined under 07-10-47
Both records are combined under 07-23-38
Each admission is filed under its own number.
Previous records are brought forward and filed under the latest number issued
Design of the workflow and processes
Physician willingness to adopt
Contribution to the quality of patient care
Individual provincial/territorial legal and regulatory issues
Visit corporate headquarters of the vendor.
Perform a vendor reference check
Read consumer reports before buying
Test the software prior to purchase
Be filed in a health record created for the infant
Be filed in the mother's record
Be retained in a separate file in the administrative offices
Not be retained in hospital records
Canadian Association of Medical Record Librarians.
Canadian College of Health Record Administrators.
Canadian Health Record Association.
Canadian Hospital Association.
British North America Act (BNA).
Canada Health Act (CHA).
Canada Health and Social Transfer (CHST) Act.
Established Programs Financing (EPF) Act.
Primary health care.
Quaternary health care.
Secondary health care.
To control costs and integrate health care services.
To improve system planning and provide greater accountability.
To enhance public participation in decision-making and emphasize population health.
All of the above.
Provide essential research and expertise in health information standards and best practice
Support continuing education and professional practice of HIM professionals
develop strategic partnerships to advance the development an integration of electronic HIM
Advocate for and strengthen the HIM role in health care settings across the continuum of care
CHIMA Strategic Goals
CCHIM Strategic Goals
Governance Strategic Goals
OHIMA Strategic Goals
Electronic Health Information Management (e‐HIM)
Health Information Management Standards