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HS410-4 Compare standards and regulations for healthcare documentation

HS410-4 Compare standards and regulations for healthcare documentation

Sample Answer 

HS410-4 Compare standards and regulations for healthcare documentation

Items to be aware of in handling Electronic Health Records

As a manager of electronic health records, one ought to be aware of HIPAA’s standards governing the healthcare provider’s operations. There are required standards that must be followed relating to the right to scrutiny and access to health records by patients and the privacy, security and confidentiality of patient’s health records. As such, the Director of Health Records must be aware of the provisions of the law relating to these two areas of managing electronic health records. The following is an in-depth explanation of the two items that the one in charge of electronic health records management must be aware of.

First, one must be aware of HIPAA’s provision on the right to access their health information. Giving easy access to an individual’s health information aims to empower them to be in charge of their decisions on health information and well-being (Health Information Privacy Division, 2016). The Health Insurance Portability and Accountability Act provides an array of rights, with exceptions on specific grounds, which are legal and enforceable to individuals to see or receive copies of their health and medical information upon request from healthcare providers maintaining them. HIPAA mandates covered entities to give individuals access to protected health information (PHI) upon request or to transmit a copy to a designated entity or person according to the owner’s choice (Bowman, 2017). Here, the Director of Health Records must know what the designated record set as is needed in the right-to-access regulations. The scope of the type of records that individuals have a right to access includes billing and medical records, claims adjudication, payment, enrollment or any medical management record systems maintained by the health provider. There is also information excluded from this provision, including psychotherapy notes and information collected in anticipation of, or for purposes of, a criminal, civil or administrative proceeding (Health Information Privacy Division, 2016). The procedure to grant access to information is also crucial to understand so as not to breach the HIPAA provisions. This encompasses the requirement for a written request, undergo verification by the covered entity, and protection from imposing unreasonable measures by the healthcare provider.

The second item that the Director of Health Records must be aware of is the privacy and security of electronic health records. Under HIPAA privacy rules, patients’ information must be protected from being accessed by other individuals apart from the patients themselves, their designated persons of choice, or those permitted by the law (Harman, Flite, & Bond, 2015). All electronic medical records must remain confidential and secure from all unscrupulous individuals who may want to exploit them for financial gains. As such, the healthcare provider has to maintain a secure system by utilizing multiple authentication access systems to enhance patient information security. The employer must implement security measures that will detect and deter unauthorized or impermissible access to patient’s protected health information. The privacy laws dictate that a violation of security and privacy requirements by the employees of a covered provider has attracted accountability by the employer, who is required to pay for such a breach. HITECH Act also mandates the provider to set the protocol to be followed to report data breaches to patients’ PHI (Kruse, Smith, Vanderlinden, & Nealand, 2017). It also outlines the pillars of securing patients’ information by addressing the technical, administrative and physical safeguards that all providers must put in place.


Health Information Privacy Division. (2016, February 25). Individuals’ Right under HIPAA to Access their Health Information 45 CFR § 164.524. Retrieved from Health Information Privacy: US Department of Health and Human Services:

Bowman, S. (2017, August 19). Understanding the HIPAA individual right of access to health information. Retrieved from Healthcare innovation:

Harman, L. B., Flite, C. A., & Bond, K. (2015). Electronic Health Records: Privacy, Confidentiality, and Security. AMA Journal of Ethics, 43-58.

Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017, July). Security Techniques for the Electronic Health Records. Journal of Medical Systems, 41(8), 127-136. doi: 10.1007/s10916-017-0778-4


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HS410-4 Compare standards and regulations for healthcare documentation

Assignment Details

Unit outcomes addressed in this Assignment:

  • Identify significant standards for healthcare documentation.
  • Understand important factors involved in regulations pertaining to paper and electronic health records.

Course outcomes addressed in this Assignment:

HS410-4: Compare standards and regulations for healthcare documentation.

HS410- Compare standards and regulations for healthcare documentation

HS410- Compare standards and regulations for healthcare documentation


Your boss is the Director of Medical Records at a large academic medical center. He is finding it difficult to monitor the ongoing legislative and policy changes related to Health Information Management. He has asked that you do the following:

  1. Visit the website
  2. Prepare a one-to-two-page report highlighting the two most important items your boss should be aware of.
  3. Recommend a course of action for each.

Submitting your work:

Submit your Assignment to the appropriate Dropbox.

To view your graded work, come back to the Dropbox or go to the Gradebook after your instructor has evaluated it. Make sure that you save a copy of your submitted work.

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