Defining Protected Health Information (PHI) PHI is at the very core of the Health Insurance Portability and Accountability Act (HIPAA) The underlying purpose of HIPAA is to ensure that the personally identifiable information in a patient’s health record is kept private and protected. This includes all health information, whether physical, electronic, or verbal. In order…
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There are many pieces of a patient’s chart, whether paper or electronic. Multiple types of documentation are required for a complete and compliant patient chart. The way the chart or file is organized is critical to proper recordkeeping. Sometimes, we take for granted how simple the chart building process is, or how we use the…
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The Health Record Asset We’ve all heard the adage, “If it wasn’t written down, it didn’t happen.” Encounters between doctors and patients are “written down” in the patient’s health record. That record is one of the most important assets owned by the practice. It is the final, legal document that describes the conditions and treatment…
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EHR vs Paper The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient’s medical history and care across time within one health care provider’s jurisdiction. The role of the health record is to keep a sequential record of all the conditions and treatment…
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Initial Visit Prompts for Providers The terms – incident, burst, and full episode of care – were created to provide a visual image for providers as they begin their clinical decision-making in the care of a patient. Doctors have a fiduciary responsibility to evaluate patients to determine the entire clinical picture. This begins with the…
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There are many definitions that must be clear when you’re running the business of healthcare, and of Chiropractic. The most important reference documents to be familiar with are the Medical Review Policies published by the payers with whom you do business. These documents outline the responsibilities of the provider when billing the services, such as…
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