Scan of ROI Request Release of information logs must be retained for 6 years. (HIPAA Privacy Rule) The following disclosures must be accounted for: Government mandated reporting Research Disclosures by business associates that are not for treatment, payment, and healthcare operations Though exceptions apply, disclosures typically included in response to an AOD request include: All disclosures of PHI that are not for treatment, payment, or delivery of healthcare operations Suspected domestic and child violence and abuse reporting Disclosures made for research unless authorized by the patient or legal representative Disclosures made to government agencies (excluding intelligence/national security) Disclosures to public health authorities Disclosures to the Food and Drug Administration Disclosures to employers Disclosures to health oversight agencies Vital statistics reporting Disclosures to law enforcement Disclosures regarding deceased persons Disclosures for research purposes Disclosures for specialized government functions Disclosures for workers' compensation purposes Appendix C: Glossary Term Definition Clinical Pathway A flow of activities and documentation derived from the clinical guidelines as related to a specific episode of care (Figure 5). Clinical pathway is a tool designed to coordinate multidisciplinary care planning for specific diagnoses and treatments. Clinical pathway also as a clinical workflow document (specification or – checklist) is developed by physicians (medical informaticians) at the – facility. It serves as a practice management protocol. This protocol defined information and data requirements (forms, documents) associated with the episode of care. The information and data requirements (forms, documents content) are also called case definitions, i.e., specific instructions on how to document specific activity within the function based on the clinical guidelines. The oversight of the correct recording of information according to the clinical pathway protocol and case definition is conducted by the facility’s Clinical Documentation Improvement (CDI) team of the HIM department. CDI team is also involved in developing templates (standardized formats) for forms and documents used in the clinical pathway to document the episode of care/encounter.
Scan of ROI Request Release of information logs must be retained for 6 years. (HIPAA Privacy Rule) The following disclosures must be accounted for: Government mandated reporting Research Disclosures by business associates that are not for treatment, payment, and healthcare operations Though exceptions apply, disclosures typically included in response to an AOD request include: All disclosures of PHI that are not for treatment, payment, or delivery of healthcare operations Suspected domestic and child violence and abuse reporting Disclosures made for research unless authorized by the patient or legal representative Disclosures made to government agencies (excluding intelligence/national security) Disclosures to public health authorities Disclosures to the Food and Drug Administration Disclosures to employers Disclosures to health oversight agencies Vital statistics reporting Disclosures to law enforcement Disclosures regarding deceased persons Disclosures for research purposes Disclosures for specialized government functions Disclosures for workers' compensation purposes Appendix C: Glossary Term Definition Clinical Pathway A flow of activities and documentation derived from the clinical guidelines as related to a specific episode of care (Figure 5). Clinical pathway is a tool designed to coordinate multidisciplinary care planning for specific diagnoses and treatments. Clinical pathway – also as a clinical workflow document (specification or checklist) – is developed by physicians (medical informaticians) at the facility. It serves as a practice management protocol. This protocol defined information and data requirements (forms, documents) associated with the episode of care. The information and data requirements (forms, documents content) are also called case definitions, i.e., specific instructions on how to document specific activity within the function based on the clinical guidelines. The oversight of the correct recording of information according to the clinical pathway protocol and case definition is conducted by the facility’s Clinical Documentation Improvement (CDI) team of the HIM department. CDI team is also involved in developing templates (standardized formats) for forms and documents used in the clinical pathway to document the episode of care/encounter.
IHE_ITIWhitePaper-HITStdsforHIMPratices_051115.docx