ABC Offers Guidelines for Maintaining Security in Patient Records The American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) offers the following relevant Facility Accreditation Standards: TIP: ALL PATIENT RECORDS MUST BE CONSISTENT. If you use photographic documentation, you will have a policy that describes how, when, and under what circumstances photographic documentation is used.
PR.6.1
Your patient records must include: 1. Patient evaluation/assessment that contains diagnosis, prescription or valid order, relevant patient history, and medical necessity 2. Pretreatment photographic documentation as appropriate for the item 3. Patient education 4. The name of the patient-care provider, his or her findings, recommendations, treatment plan and follow-up schedule
The ABC Code of Professional Responsibility also addresses this subject. The Code states the following:
C3.1 Confidential Information
All patient information derived in a workplace from a working relationship relating to any patient shall be held and always remain confidential by all parties unless there is written permission to release the information.2
Ensuring Clarity and Security in Patient Records
As mobile devices become a part of daily practice, mobile device security is an obligation: It’s imperative to protect your patients’ health information. O&P business owners and practitioners must evaluate the risk associated with using mobile devices to capture video and pictures—but should not avoid using mobile devices simply because they are unsure of the facts. These tools can capture valuable health-care information if used properly. A simple video-based system could document the fitting process, reduce a certain amount of trial and error, facilitate treatment planning, provide video feedback for training, and act as a communicative tool among the orthotist/prosthetist, the rehabilitation team, the patient, and the insurer. Some O&P professionals have voiced concerns about the question of safely implementing the use of smartphones into clinical practice.1 The biggest concern relates to emailing
photos and videos: Some practitioners caution against using unencrypted email servers to send information such as photos and videos. But there are other avenues available for sharing photos and videos. By learning about these options for safe image capture and storage and putting relevant policies into place at your facility, you can protect your patients. O&P professionals can look to guidance from the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) for assistance in determining the rules for patient documentation safety. (See sidebar on this page.) Then office owners and managers can follow the ABC guidance in implementing facility policies for visual documentation. It’s important to be consistent when developing guidelines for capturing and storing patient photos and videos. Start by determining the purpose for the visual documentation, and determine to what extent the information will be used. Will you create a process to take O&P ALMANAC | FEBRUARY 2015
33