You are the director of the medical records department. Your facility is adjusting to the newest regulation of the 21st Century Cures Act, granting patients access to their entire medical record. You have been asked to write a policy surrounding this legislation.
Write a policy containing these 4 sections:
- Overview: Define the 21st Century Cures Act and how it affects the release of patient records
- Documentation of Sensitive Information: Outline how health care professionals should appropriately document information in patient charts — specifically, disruptive behavior and substance abuse — demonstrating sensitivity as the patient will be able to access this documentation in their chart.
- Information Blocking: Define information blocking and the guidelines surrounding information blocking in the 21st Century Cures Act. Provide 2 examples of information blocking in health care.
- Patient Complaints: Outline the process to address patient complaints about documentation in their record. Explain when a patient can make a complaint concerning possible information blocking as well as explain the complaint and investigation process. Provide 2 examples of patient information blocking complaints that would need to be investigated by the compliance department of an organization.