FINAL Global Module 10-11.pdf - AaronsWorld.com

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Patient Access Clinicians may not give patients unsupervised access to their charts at any time. Leaving charts unattended in the treatment room with patients jeopardizes the integrity of the record, because patients may alter or remove parts of the clinic’s official treatment documentation. Similarly, clinicians may not bring one patient’s chart into the treatment room while treating another patient. If patients wish to view their records, please have them contact the medical records manager or medical records coordinator to schedule an appointment to view them. COMMUNICATION RESTRICTIONS Preview-Review Sessions Patient information is discussed only in preview-review sessions in a manner that omits uniquely identifying information. Discussions should be limited to the patient’s age, gender, and medically relevant information necessary for learning and conducive to the advancement of clinic competency. Clinicians may refer to patients using the initials of the first and last names for clarification in discussion. It is not appropriate, however, to use a patient’s name, date of birth, or personal account information in preview-review discussions. Moreover, discussions may not include names of relatives or known acquaintances, specific occupational information, or any other uniquely identifying acts. (See clinic de-identification policy for complete list of uniquely identifying elements.) Records designated (i.e. labeled) as ‘restricted’ may not be discussed in preview-review sessions. Restricted records include records of students, staff, faculty, and their immediate relatives. Such records are only discussed among the clinicians directly involved in the patient’s care. Similarly, restricted records may not be used for grand rounds summaries or discussed among clinicians not directly involved in the restricted patient’s care – even if this discussion does not include uniquely identifying elements. Faculty may opt to restrict access to an individual’s chart by notifying the medical records manager. The medical records office will make the necessary changes and grant the chart ‘restricted’ status. A student clinician may not grant a record restricted status. Public vs. Private Areas Patient cases may only be discussed freely in private areas. Treatment rooms, private offices, designated preview-review areas, or closed classrooms and conference rooms are sufficiently private to allow free discussion of patient information. It is inappropriate to discuss patient cases in hallways, waiting rooms, or other public, non-secure areas using any uniquely identifying information. Clinicians must never discuss medical treatment with a patient in a public area at the clinic, even if the patient consents to such discussion. Not only could such a discussion result in a misunderstanding about what was acceptable subject matter, but could also present a poor image to other patients. Discussion of patient cases outside the clinic must be done in a manner that excludes all uniquely identifying elements. Students are to refrain from discussing other student cases outside the clinic entirely – even in a de-identified fashion. Minimum Necessary Standard Clinicians are required to abide by a ‘minimum necessary standard’ when discussing patient information with other clinicians not involved in the patient’s health care or when discussing such information with staff members of various departments. Clinicians may only discuss patient information to the extent necessary to accomplish the task at hand. It is inappropriate to discuss patient medical information with staff or faculty not directly involved in a patient’s health care, if disclosing such information is not necessary in order for that staff or faculty member to perform his or her 40
essential work duties. Clinicians shall use their professional judgment in determining what information is necessary and appropriate to communicate. Releasing Information Clinicians are prohibited from releasing patient information, with the exception of releasing information to a patient, the patient’s legal representative, or another health care provider involved in the patient’s care, when the release is either verbal (in person or over the phone) or in the form of a summary/referral letter (i.e., does not involve copying chart notes). The medical records office must process all other releases including faxes. All other inquiries for patient information are made by contacting the medical records helpline at (206) 834-4151. If a clinician wishes to enclose chart notes along with a summary/referral letter, the medical records office must provide the enclosure and mail the letter on the clinician’s behalf. All questions concerning representative authority are directed to the medical records office. (See Medical Records section below for more information on records releases.) Faxing of patient information Clinicians who need summary and referral letters faxed to other health care providers and a copy of the correspondence placed in the chart, should request this of medical records Students must first call and verify all fax numbers with the receiving party prior to faxing. Clinicians are not to fax copies of chart notes, such as labs, progress notes, or other uniquely identifiable information to any third party, including other health care providers. All such releases must go through the medical records office. All incoming faxes containing patient medical information must go to the medical records office at (206) 834-4131. Incoming faxes containing any patient information should NOT be directed to the any other clinic fax number. E-mailing patient information Clinicians are prohibited from e-mailing patient information unless the communication is with an authorized clinician or staff member, and the e-mail correspondence is neither directed to, nor originates from, an external server. For example, a clinician may use an assigned faculty or student e- mail account (@bastyr.edu) to e-mail patient information to another authorized staff member or clinician within the organization (@bastyr.edu). E-mailing patient information from or to an e-mail account at external servers, however, such as Hotmail©, Yahoo©, America Online©, etc., is prohibited and constitutes a wrongful disclosure. In addition, when a clinician or authorized staff use e-mail for patient follow up (e.g. Supervisor e- mails student that patient’s labs are in, please call patient with these directions) they must ensure that all e-mails de-identify patient information. For example: if Sue Smith was seen in the first hour in room three of Dr. Robert’s Thursday afternoon shift, the e-mail could state: Labs are in for JS, first hour patient on your Thursday 2.0 shift from March 5 th . Please call her and ask her to make a follow up appointment to review the labs and set up a treatment plan. Please document the phone call and forward the chart to me to sign. Please Note: this internal email communication is not part of the medical record and should not go into the chart. Student clinicians may not correspond with patients via e-mail and must direct any such communications to their faculty supervisor upon receipt. 41
Page 1: TABLE OF CONTENTS TABLE OF CONTENTS
Page 4 and 5: II. CLINIC SHIFT POLICIES AND PROCE
Page 6 and 7: DRESS, HYGIENE, AND APPEARANCE REQU
Page 8 and 9: Integrated care shift - This shift
Page 10 and 11: Students will receive a grade of AC
Page 12 and 13: GRADING AND STUDENT PERFORMANCE Cli
Page 14 and 15: If students wish to file a grievanc
Page 16 and 17: o Violation of the Bastyr Center fo
Page 18 and 19: CLINICIAN RESPONSIBILITIES - PRIMAR
Page 20 and 21: CLINICIAN RESPONSIBILITIES - SECOND
Page 22 and 23: DOCUMENTATION GUIDELINES (DG) Basty
Page 24 and 25: REFERRALS Patient Referral To BCNH
Page 26 and 27: NEEDLES NEEDLE STICK OR EXPOSURE IN
Page 28 and 29: IN CASE OF A SENTINEL EVENT A senti
Page 30 and 31: SUICIDAL/HOMICIDAL PATIENT PROCEDUR
Page 32 and 33: EMERGENCY PROCEDURE PROTOCOL FLOW S
Page 34 and 35: o The nature of the incident. o The
Page 36 and 37: o The student services office. o Th
Page 38 and 39: *Names of Bastyr clinicians and fac
Page 42 and 43: MEDICAL RECORDS The medical records
Page 44 and 45: Faculty providers frequently receiv
Page 46 and 47: Check the form for completeness. Ha
Page 48 and 49: Exceptions Below is a list of the e
Page 50 and 51: GRIEVANCE/COMPLAINT POLICIY V. MISC
Page 52 and 53: CLINIC CLOSING TIME In general, the
Page 54 and 55: VI. APPENDICES I. CLINIC CONTRACT I
Page 56 and 57: Appendix 2 Bastyr University Health
Page 58 and 59: Appendix 4 MEDICAL ABBREVIATIONS Th
Page 60 and 61: GB gallbladder GC gonorrhea GH grow
Page 62 and 63: q (spell out) qam qd qh q2h qid qpm
Page 64 and 65: Appendix 5 PATIENT CO-MANAGEMENT: T
Page 66 and 67: Today’s Date Dr. Primary Care Doc
Page 68 and 69: Today’s Date Doctor Name Doctor A
Page 70 and 71: Impression: I am concerned about th
Page 72 and 73: CLINIC PHONE DIRECTORY Bastyr Cente
Page 74 and 75: AOM Clinical Faculty: Terry Courtne
Page 76: ND Residents: Jessica Bean, ND 1st

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