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Subject: Patient Record Management
Effective Date: December 2015
Effective Date: December 2015
Purpose
To establish uniform procedures detailing the responsibilities of dental providers (including Employee, Faculty, Affiliate Faculty, Pre-doctoral and Graduate Students) who administer treatment to patients of record within the School of Dentistry (herein referred to as “SOD”) to compile and maintain patient treatment records. This policy is intended to ensure that all patient recordkeeping is maintained by treatment providers at the SOD in a manner that is fully compliant with all relevant laws and regulations.
General Policy
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The SOD employs a patient Electronic Health Record (herein referred to as “EHR”) system called axiUm and a patient radiograph record system called “MiPACS.”[1] Dental providers engaged in all levels of patient related clinical activity must adhere to strict policy guidelines and regulatory requirements when entering patient treatment notes and records in axiUm and MiPACS.
Such requirements also apply to approval of student notes and procedure codes compiled during clinical teaching activity. Claves de interpretacion biblica tomas de la fuente pdf free. This policy sets forth: (1) rules for timely input and/or approval of patient treatment notes and procedure codes; (2) monitoring and corrective actions taken for non-compliant treatment providers; and (3) an enforcement mechanism – that will ensure that SOD remains in compliance with all applicable statutory and regulatory requirements.
Implementation
I. Legal and regulatory requirements
Washington state law governing the “Maintenance and Retention of Records” requires that dentists compile and maintain comprehensive and dated patient treatment records. The statute expressly states that, “[any] dentist who treats patients in the State of Washington shall maintain complete treatment records regarding patients treated” (Washington Administrative Code (WAC) section 246-817-310).[2] Furthermore, such treatment records, once compiled and recorded under the above provision, must be maintained in compliance with federal law governing confidentiality of patient records under the Health Insurance Portability and Accountability Act of 1996 (herein referred to as “HIPAA”).[3] Under HIPAA and the SOD’s EHR policy, the obligation to ensure patient confidentiality extends to:
“…electronic exchange [of] financial and administrative transactions [for] health claims or equivalent encounter information; [such as] health claims… healthcare payment[s]… [including] unique health identifiers… [i.e. procedure] codes… for appropriate data elements for […] transactions… [including] audit trails in computerized record systems… (HIPAA Sec.1173 (a) “Standards to Enable Electronic Exchange”).”[4] Gmail stuck on sending.
II. Provider obligations
The following are the requirements adopted by the SOD, concerning the obligation of our providers to compile and maintain proper patient treatment records (regardless of whether the patient visit is considered a paid visit or a no-charge follow-up visit)
- Faculty – In recording treatment notes, faculty must utilize the SOAP format as stated in the SOD’s Health Information Management Policy, Section 3.1 of the Clinic Policy Manual for Faculty & Staff (herein referred to as Clinic Policy Manual). Notes must be completed, at the end of the treatment day or no later than twenty-four (24) hours following the patient appointment and in anticipation that the patient will be seen by other clinics and specialties for on-going treatment and/or for revenue cycle purposes. Please refer to the Clinic Policy manual for clarification and structure of SOAP notes. Furthermore, if scanning of patient notes, treatment plans or any other format containing information that cannot be captured in an axiUm form is used, there must be a separate fully structured and formatted SOAP note in the axiUm format within the above-mentioned time frame. In sum, all patient recordkeeping must be properly and promptly recorded in axiUm and/or MiPACS.
- Affiliate Faculty – Affiliate faculty must adopt the above-described policy utilizing the SOAP format but are required to complete and approve all treatment notes and procedure codes by the end of their assigned clinic session on the same day.
- Pre-doctoral, Graduate and Resident Students – Students engaged in patient clinical activity in a pre-doctoral, graduate, or resident program at the SOD must also follow the patient recordkeeping standards set forth in the Clinic Policy Manual. Students at all levels should complete their notes and input treatment codes by the end of their clinical session on the same day, for faculty approval. It is the student’s responsibility to obtain required faculty approval of their patient chart notes and procedure codes within the twenty-four (24) hour guideline. If a student has been monitored by an affiliate faculty member – he/she must get such notes and procedure codes approved by the end of the session.
- All SoD providers – Enforcement of Policy- Chart notes for Urgent Care Patients in 24 hours and for Routine Treatment at 7 days.
II. Training, communication and monitoring
A. Training & Communication
The SOD will reinforce training and support its providers in complying with treatment record requirements by:
- Creating and providing treatment providers with instructions on axiUm and MiPACS protocols for patient recordkeeping.
- Creating and providing hands-on training and reference materials for treatment providers on accepted practices of patient recordkeeping.
- Providing updates and/or refresher training to ensure compliance.
B. Monitoring
Monitoring will occur on two or more levels to quickly identify deficiencies and implement corrective measures before clinical processes interact with the revenue cycle process.
- “Front-line” verification to ensure that patient recordkeeping is completed and approved for processing through the revenue cycle will be conducted by:
- Clinic Floor Personnel – prior to the patient and treating provider going to the front desk and/or;
- Front Desk staff – upon check out with treating provider and/or;
- Clinic Manager – at the end of a session.
- axiUm reports will be generated on a weekly basis to ensure continual compliance and as an added layer of checks and balances with respect to:
- Lack of or missing treatment notes or procedure codes; and/or
- Unapproved procedure codes and notes; and/or
- Unacceptable standards or patient recordkeeping in axiUm (i.e. scanning or other form of recordkeeping not consistent with SoD standards)
- Timely Reporting of infractions: Report on-going deficiencies past seven (7) days but no later than fourteen (14) days to the Associate Dean for Clinics for appropriate action.
III. Enforcement
A. Warnings
To ensure that the SOD remains in overall compliance with state regulations and licensing obligations, the following corrective actions shall be employed:
- First Warning: Written communication via email and/or letter informing treatment provider and the department; suspension of clinic privileges (including faculty practice activities) if the issue is not corrected within 2 weeks from the time of the procedure. If compliance is met within timeframe, no formal record will be placed in faculty file.
- Second Warning: Elevate infraction to Associate Dean for further action if not mitigated within thirty (30) days. A permanent record of infraction noted in treatment provider’s records; disciplinary action including, but not limited to suspension of faculty practice activities, a “non-meritorious behavior” citation, and further attention regarding performance of the faculty member.
Dean of UW SOD:
Joel Berg, Dean of the UW School of Dentistry
December 21, 2015
[1] Medicor Imaging Picture Archiving and Communication System – “MiPACS”
[2] See also Revised Code of Washington (“RCW”) § 18.32.655, Washington State registry (“WSR”) §§ 95-21-041 and WAC 246-817-340.
[3] See also RCW § 70.02 Gateway p7811fx driver for mac.
[4] http://www.hhs.gov/ocr/privacy/hipaa/administrative/statute/hipaastatutepdf.pdf ; accessed 05Oct2015.
Virtual Desktop (VDI), allows us to access a virtual copy of axiUm from any web browser.
The intention is to allow students, staff and faculty full access to axiUm outside the school. Here are some general rules that we have come up with that should frame your use of VDI.
Use of Virtual Desktop (VDI) - Some Rules of the Program:
Here are things you CAN do:
Note that during the COVID19 emergency, Dean Karimbux approved for us to write notes, complete some procedures, and approve those notes and procedures off site.
- Always use a privacy screen when you are out in public.
- Please put your screen saver on so that it automatically locks within 5 minutes of inactivity.
- Never leave your computer unattended.
- You may access VDI from any web browser.
- You may do almost everything in axiUm except items that need a swipe or a signature. Below is a list of common activities:
- You may view and request appointments
- You may enter information into the contact notes.
- You may update medical and dental information if a patient gives that information to you.
- You may develop a Treatment Plan, it just cannot be approved.
- You may update the Odontogram.
- You may view axiUm messages.
- You may use a computer or an iPad to access VDI, however a phone will make the screen too small to see.
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Here are things you CANNOT do:
- Please DO NOT access VDI when you are in a public location. There is the possibility of seeing Protected Health Information when in a public location; therefore, we respectfully request that you do not use it when in a public location.
- No case/treatment notes should be written on a case off campus. (This rule may be adjusted by the Dean in case of emergency)
- No prescriptions should be written off campus. (This rule may be adjusted by the Dean in case of emergency)
- No Consents or approving Treatment plans can be done off campus as they require a signature from the patient. (This rule may be adjusted by the Dean in case of emergency)
- Periodontal probing documentation should not be updated.
For the duration of the clinic closure due to the New Corona virus pandemic, Dean Karimbux approves the use of VDI access for students to write notes and for faculty to approve procedures, forms and case notes to facilitate management of student rosters and transfer of patients. When the clinic reopens, this message will be deleted and the rules will return to normal.
Axium Dental Software Manual
Please be mindful that there are consequences if Audit Report indicates that inappropriate access/attempts to access information are determined:
- First offense: Verbal warning
- Second offense: Removal of access to VDI for one month.
- Third offense:
- Faculty: report to Department Chair
- Staff: report to Staff Supervisor, with subsequent following of appropriate process.
- Student/Resident: report to EPC
Here is how to access axiUm while you are off campus:
- Open a browser
- Connect tohttps://vdi.it.tufts.edu/
- Click on the right icon “VMware Horizon HTML access”
- Enter your Tufts username and password & click Login
- Select AxiumCIS – Dental Clinical Services
- Once the windows desktop appears, click on Axium icon
- Login as normal
To disconnect:
- Logout of axiUm
- Close the desktop by clicking Start/Logoff
- Close browser page
For a positive experience, please refer to the below instructions: 3d box creator.
- It is best to use Safari for Mac, Chrome for Mac or Windows.
- If using a laptop and experiencing a resolution error, reduce the Zoom on your browser to approximately 75%.
- Both Chrome & Safari have this feature, and it can be adjusted regardless of what website you are visiting.
- Once the Zoom is reduced, open your patient EHR (most common module requiring the resolution).
- With the EHR open, you can adjust the Zoom back to 100% or your personal preferred level so it is not difficult to read.
- Leave the EHR open when switching between patients, this will ensure you do not have to keep adjusting per patient.
- If using a laptop and size of text or icons is too small, you can increase the zoom on the browser using the same steps.
- Reference links below detail the use of the features described above for each browser.
? Safari (Apple):https://support.apple.com/guide/safari/zoom-in-on-webpages-ibrw1068/mac
? Chrome (Google):https://support.google.com/chrome/answer/96810?hl=en
Any issues with these instructions, please feel free to write or call the Help Desk: [email protected] 617-637-3376.