Best way to handling corrections revision of the Patient Record

The rules to modifying the Patient Record should be strong foundation for the enterprise seeking to develop policies and procedures. In order to ensure the admissibility of the medical record as evidence, the enterprise must first establish policies and procedures that address

• Author authentication
• Medical record access control
• Medical record archiving and retention
• Medical record security

• Medical record disaster recovery policies and procedures

By establishing controls over the creation of medical records, enterprises can ensure the nonrepudiation of corrections, revisions, additions, and addenda made in the normal course of business.

Ultimately, by controlling the how, who, where, and when of creating the medical record, the enterprise establishes the methodology for performing valid corrections, revisions, additions, and addenda.

The best practices of a healthcare enterprise can develop an effective and valid policy and procedure for the correction, revision, addition, and addenda of health information contained within the electronic medical record.

The key characteristics of an effective policy and procedure include

• Author authentication and accountability
• Clear indication of correction or amendment date and time
• Policies and procedures that prevent unauthorized alteration of documents
• Clear delineation of parent document
• Clear delineation of corrected or amended document
• Notification of health information recipients when amendments and corrections occur
• Retention of the parent document for historical reference

Though it is true that no single rule that addresses medical record correction and amendment exists, enough guidance is available to allow healthcare service providers to develop a workable policy and procedure to address the creation of valid medical record corrections and amendments.

Medical Transcription: Adopting the Right Network Security Audit

The HIPAA compliance norms make it necessary for the health entities and their business associates like medical transcription company to incorporate a security audit system in the network. The purpose is to maintain vigil on the all the electronic transactions of patient health information, flowing in and out of the network. Security audit brings in accountability in the transcription process and pinpoints the offender in case of breach in privacy of patient health information.

The audit system should have features, which enable complete and constant monitoring of the computer network. It should bring to notice of network administrators, any unnatural activity so that a timely intervention can prevent hostile intrusion. If however a lapse does occur the auditors can know, how and when the event happened, and who did it.Keeping in mind the sensitive nature of patient electronic health report information, it is necessary for the medical transcription company to adopt right network security audit measures. These are mentioned below:

• It should record time, nature and type of login. This deters hostile users like hackers and at same time keeps tabs on what type of information is accessed by the authorized user.

• Able to provide the log off time, details of the user and type of information accessed before the log off occurred.

• Provide detailed report on unsuccessful login, which includes the username, the number of attempts, date and time. This feedback is used to increase the vigilance and further strengthen the network.

• Able to pinpoint the objects accessed, like a file or directory and the whether the content was read, copied, deleted or modified. It should provide a feedback on the integrity of the content so that if any changes are made, the administration knows whether these changes where legal or illegal. This is necessary as per HIPAA compliance norms.

• Maintain complete record of the start-up and shut down time of the computer network.

• Able to maintain complete record of both successful and unsuccessful login of authorized users like medical transcriptionists.

• Store and protect data for a desired time limit.

• Provide auditors easy access to the desired data.

• Ability to monitor the message flow, in and out, of the network. The security audit should track who sent the message to whom and what was in it.

It is mandatory for medical transcription service providers to ensure HIPAA compliance of their networks, other wise they risk severe penalties or criminal convictions. A right auditing system does round-the-clock surveillance of computer network and raises alarms against hostile intrusion. This is completely in line with HIPAA compliance norms.

The security audit protects the patient health information in the network through continuous vigilance.