This document outlines policies and procedures for an electronic medical records (EMR) system. It discusses regulations like HIPAA that protect patient privacy and payment information. It describes responsibilities for ensuring accurate, timely data entry and maintaining security of records. Staff must have limited, tracked access according to their roles. Records require signatures and are only available to authorized personnel. Disciplinary actions may occur if policies are breached. Corrections to records involve adding an addendum rather than deleting original entries.

1. EMR Policy & Procedures By Shannon Hullum

2. Passed by Congress in 1996 to set a national standard for electronic transfers of health data. To protect the privacy of medical information To protect payment information Policies and Procedures Purposes Confidentiality Authenticity of users Timeliness and accuracy of data entry Failure to comply results in disciplinary actions Regulations - Purposes Health Insurance Portability and Accountability Act (HIPPA) An accent, click to edit the text inside. An accent, click to edit the text inside.

3. Proprietor of EMR Patients may access, copy, and request amendments to their medical records via request to the institution that created the file

4. Health information management (him) Medical staff This department is responsible for the safety and security of EMRs Deals with maintenance, accessibility, data integrity and quality, and retention of data Protects records from unauthorized or accidental changes Petitioned for patient information Assures proper collection, gathering, and presentation of records for legal and administrative use Responsible for documentation entered into the EMR The information must be timely, accurate, pertinent, and complete Staffing Responsibilities

5. Employee Accessibility & Security Standards Procedures should be strictly enforced Limited to those directly involved with patient care Records Secure passwords and or access codes IDs Full signatures and or initials for each entry Signatures Data exclusively available to personnel or department according to need, firewalls for outside access, audit trails for user tracking Security

6. Discipline Breech Investigation Consequences

7. Corrections Instead of a deletion, an addendum is added to the existing record Documents must include a signature, date, time, and reason for amendment Advantages Enhances safety, value, and efficiency of patient care Accuracy of Records

8. References Legal medical record standards. (2008). Retrieved from http://www.ucopedu/ucophome/coordrev/.../legal-medical-record-policy.pdf HIPPA basics: Medical privacy in the electronic age/ Privacy rights clearinghouse. (2011). Retrieved from http://www.privacyrights.org/fs/fs8a-hipaa.htm