Wiki HIPAA timeframe for completing documentation for an encounter

[cspair@outlook.com]

This may be an unusual question, but I'm hoping someone out there can guide me to the answer.

The provider at my clinic is from a much older generation. As such, he has been rather slow to embrace EMR and relies heavily on his handwritten notes when examining patients. After the encounter, the medical assistants input his handwritten notes into the patient's EMR and make sure every scrap of written documentation- from his notes, to the scripts, to any radiology, etc.- has been scanned into the computer and attached to the patient's chart.

As the coder/biller/auditor, I then code the encounter and check it for accuracy. It is then presented to the provider for his final approval and to be electronically signed. It's an overly drawn out process for something that really shouldn't be so complicated.

How long is too long to complete this process? I ask because sometimes we get patients who want all of this documentation in their hands the day of the visit- not just the vitals or a quick summary. Legally, is there a timeframe for us to follow to comply with their request?

Thanks!

 

[Skymom]

Timeliness in Providing Access

In providing access to the individual, a covered entity must provide access to the PHI requested, in whole, or in part (if certain access may be denied as explained below), no later than 30 calendar days from receiving the individual’s request. See 45 CFR 164.524(b)(2). The 30 calendar days is an outer limit and covered entities are encouraged to respond as soon as possible. Indeed, a covered entity may have the capacity to provide individuals with almost instantaneous or very prompt electronic access to the PHI requested through personal health records, web portals, or similar electronic means. Further, individuals may reasonably expect a covered entity to be able to respond in a much faster timeframe when the covered entity is using health information technology in its day to day operations.

If a covered entity is unable to provide access within 30 calendar days -- for example, where the information is archived offsite and not readily accessible -- the covered entity may extend the time by no more than an additional 30 days. To extend the time, the covered entity must, within the initial 30 days, inform the individual in writing of the reasons for the delay and the date by which the covered entity will provide access. Only one extension is permitted per access request.

 

[allop24]

Access to Medical Records

Answers to your question are discussed in the following HIPAA ABC video from HIPAA Associates. I hope it helps you.

Al Lopez

[video=vimeo;282951883]https://vimeo.com/282951883[/video]