Confidentiality and Health Information

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Confidentiality of Health Information, HIT 109 Research project number (40903400) The American Medical Association (AMA) has established nine guidelines to assist physicians and computer organizations to provide the confidentiality of health care information in his/her medical record when saved in computerized databases. The following eight questions contain AMA Opinion 5.07 – Confidentiality: Computers nine guidelines information. Question 1: Should corrections be date and time stamped? Within the health care industry, mistakes can and are made in a patient’s paper or electronic medical record(s) (EMR’s). When mistakes appear, it is important for the authorized personal that made the original entry to make corrections to a patient’s medical record(s). (McWay, 2003, p.73) For a correction to be made in a paper medical record(s), the correct way is to draw a single line through the incorrect information and write “error” next to it, along with the date, time and initials of the authorized personal that made the original entry. Wherever appropriate in a patient’s medical record(s) there should be noted the reason(s) for such corrections made. (McWay, 2003, p.73) As far as corrections made to EMR’s, the same principles are implemented just as paper medical records. The change is the way of making a correction. Usually the correction is by way of an attachment to an EMR. Separate from the paper medical record, a new document is created showing the correction(s) and computed to the EMR with a computer code as a reference to indicate as an attachment to the original document. An electronic signature is required to confirm the attachment. (McWay, 2003, p.73) Question 2: When should the patient be advised of the existence of computerized databases containing medical information about the patient? The existence of

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