Patient viewing your documentation

[n5iln]

Nursing Home personnel also would like show that you did more then walk in, take a refusal and leave.

I did just see this issue discussed in a recent journal. This issue actually has very little to do with HIPAA, but rather it is more of a "transfer of care" issue between two healthcare providers. This is similar as to when you hand off a copy of your PCR to the ED. For the patient, new forms with specific information now show you have transferred the responsibility to patient that he/she was informed and he or S.O. can read about it again if he forgets what you said. You may also see an improvement in "transfer of care" for the patients (BLS routine) that are picked up at hospital to be transported to other facilities, ie nursing homes, dialysis, HBO etc.

Herein lies the rub. A proprietor home is NOT a health-care facility. It's a group home operated by a third-party contractor who maintains the facility, makes the meals, does the laundry, keeps the lights, heat and cable on, and hands out meds. This one has a LPN on duty eight hours a day, five days a week, to inventory and count meds into residents' boxes for later distribution. Beyond that, there's a MSW in charge of the place, several staff members to see to the regular needs of the residents...and that's pretty much it.

Of all of them, ONLY the LPN could be considered legally qualified AND have the "need to know" to review my PCR. And since we only transport OUT of the facility (evaluations and the like), that takes away the "need to know" unless either the ER doc or the patient's own doc decides to clue the LPN in on what happened in the ambulance or at the hospital...not likely; the LPN will most likely get a set of discharge instructions and an updated med sheet.

In short, there is NO transfer of care from our crews to the proprietor home; it's only the other way around. So complying with HIPAA means they DON'T get a copy of my PCR, or, in this case, the refusal form...although they're more than welcome to review the patient instruction sheet that I provide a refusing patient.

[VentMedic]

This type of home would also have a contractual agreement with the state that licenses it and must also abide by certain agreement of care for adequate supervision of care and appointed agents. The person calling you on behalf of the home and the patient then may become an agent of that facility as defined by your state's guidelines. In order for them to maintain their license to operate they must show that they have extended the offer of adequate medical assistance to a patient in a timely manner. This has been a huge legal issue and has resulted in the pulling of licenses from these facilities for failure to act or to provide adequate documentation when brought before their licensing board. I would not blame anyone for wanting to cover themselves if they were acting on behalf of the home and the patient. This again depends on the contractual agreement this home has with the state and various reimbursement agencies. An agent does not have to be a licensed medical person under most guidelines for these facilities. HIPAA also covers authorized agents in its regulations. Transfer of care does not necessarily mean leaving the facility. Your minimal contact with that patient may legally bind you for that moment of care. You will then, in good faith, leave that patient in care of themselves or another person. Was there adequate communication between all parties involved? The best way to assure this is by something in writing. Since you are the evaluating party and have accepted refusal by the patient it would then fall on you to ensure adequate communication has been provided.

[Just Plain Ruff]

We have a couple of these homes in service areas I work and have worked in.

I actually helped my mother place my aunt in one of those facilities. The caretaker does not even have the obligation to provide any type of medical care. He said that 911 would be called but he would provide no medical care after that. When asked about CPR knowledge and he said he was not required by law to have that class so he did not plan on pursuing getting trained. He was very apathetic to many things.

He seemed like he cared about the residents but when pressed about medical care he said that he relied on the local ems providers.

We placed her there and within 4 weeks she had fallen in her room and lucky me got to go get her. Fractured her hip and when we placed her in the nursing home for rehab we recieved a call to come get her stuff. They were removing her from the home due to her being in a nursing home at the time. They had already rented her room out. We were paying for her stay there out of her personal money and not insurance. The jerk said that since she was in a nursing home that he didn't have to keep her room for her.

My mother was pissed and called the national office of the company and they said that what the local operators do is not their problem or concern they have carte blanche to do whatever they want.

Needless to say - I don't recommend any home like this.

[VentMedic]

Needless to say - I don't recommend any home like this.

I'm sorry for your bad experience. Dealing with a loved one and the healthcare system takes a whole new understanding of the word "quality".

But please don't be so hasty to judge. Again it all depends on the State and its contractual agreement. Some states take their responsibility very seriously and actively monitor these homes. Some of my patients prefer them because they still feel like they have some independence and are in a more residential type setting.

Although I myself have seen a few that resembled army barracks style living rather than the home bedroom. So, it is hard to put a blanket statement on these homes.

I personally cringe at the mention of nursing homes. Yet, when it came time to place my 91 y/o mother in one, I had to try to "shop" objectively according to her long term insurance allowance.

Many are established with good intentions and many are established out of money. That is why the oversight of these facilities have gotten tougher over the past few years.

[AnthonyM83]

I've only been asked by a patient to see their PCR once, but this girl was ready to sue. She had alluded to it from the moment we were putting her in c-spine (it was a low speed bus accident). During transport she began asking ME shady questions during my detailed physical about being alone with patients in the back. I decided to just sit back the rest of the trip, monitor, and document what she had said.

She tried arguing that it was HER medical record, but I told her it was our documentation OF her and still our record, but that she could obtain a copy from the hospital upon discharge. (I still wasn't done writing it)

[Just Plain Ruff]

Anthony, that situation you were in was a precarious one.

Fortunately for you nothing has come of her questions of you and her in the back of the ambulance but if something did come out of it and she accused you then you would be the one having to prove your innocence as everyone in the media would have gotten wind of it and they would have had a field day.

I can just see it now.

Headline Anthonyville "Veteran Ambulance Driver accused of (insert your own story here)"

ONce that accusation is out then you and any provider out there are screwed with a foot thick pole. There is no way to clean up your name after that has been accused. Even if you were completely totally and utterly innocent you will always be seen or considered the one who did the unthinkable. It totally sucks.

One accusation and an otherwise stellar career is down the crapper.

I'm glad it didn't come to that.

Best thing is to document the heck out of those types of dirtbags. Those types of people make me sick.

Let's be safe out there people.

[JPINFV]

I've never had the "sue ready" patient while working on the ambulance, but I've had a few come into first aid at my waterpark job. Of course these patients are easy to deal with in this setting because I can punt their complaining to the supervisor incharge of the park, we almost NEVER hand out any sort of report with the parks name to ANYONE, and even that has to be cleared by at least the park's assistant general manager [if EMS wants a copy when transporting one of our guests then we have a seperate form that we can quickly fill out that lacks indentifying marks], and finally, the report is normally not finished until the guest leaves first aid [we don't require a signature].

As far as on the ambualnce, the signature spot for the patient is on the front of the run sheet and the HIPAA notice is on the back.

[whit72]

"Up too and including death." That is my favorite line, everyone gets that no matter what the complaint. I usually have a relative or someone on scene with them sign as a witness.

Refusals are usually easy to discard in court due to the fact that they could have been signed under duress. So I explain to the pt. and someone with them so they understand the risks of refusing treatment. Then they both sign and I am on my way.

[n5iln]

This type of home would also have a contractual agreement with the state that licenses it and must also abide by certain agreement of care for adequate supervision of care and appointed agents. The person calling you on behalf of the home and the patient then may become an agent of that facility as defined by your state's guidelines. In order for them to maintain their license to operate they must show that they have extended the offer of adequate medical assistance to a patient in a timely manner. This has been a huge legal issue and has resulted in the pulling of licenses from these facilities for failure to act or to provide adequate documentation when brought before their licensing board. I would not blame anyone for wanting to cover themselves if they were acting on behalf of the home and the patient. This again depends on the contractual agreement this home has with the state and various reimbursement agencies. An agent does not have to be a licensed medical person under most guidelines for these facilities. HIPAA also covers authorized agents in its regulations. Transfer of care does not necessarily mean leaving the facility. Your minimal contact with that patient may legally bind you for that moment of care. You will then, in good faith, leave that patient in care of themselves or another person. Was there adequate communication between all parties involved? The best way to assure this is by something in writing. Since you are the evaluating party and have accepted refusal by the patient it would then fall on you to ensure adequate communication has been provided.

That still leaves the question of what constitutes adequate communication, and whether the staff member on duty is or is not a care provider permitted under HIPAA to receive and review patient-care documentation by the ambulance crew.

I learned this evening that the Operations Manager is going to be discussing the matter with the manager of the facility to determine what documentation will be necessary for the home to meet its reporting needs. My guess is that the home will have to develop its own form that the senior medic on the crew will sign indicating either "transported" or "evaluated/no transport". I'll know more when I go in for my next shift on Friday.

[VentMedic]

That still leaves the question of what constitutes adequate communication, and whether the staff member on duty is or is not a care provider permitted under HIPAA to receive and review patient-care documentation by the ambulance crew.

Your PCR and your refusal form and/or instructions for the care giver should in actuality be 2 different forms. This is the area that leaves EMS wide open for scrutiny and this is not necessarily meant to be a HIPAA issue. Even in the strict hospital environment, the "transporter" or a volunteer who takes the patient from point A to point B has access to certain necessary information with the ability to give it quickly to a response team if something happens to the patient while in his/her care. This information is provided anytime the patient leaves the primary care giver's sight (usually nurse but can be any ancillary staff ie special tests). The transporter will not move the patient until they are sure that information is available. No, they do not need to know their SS# or insurance, but some vital information is always available for ready access. So, no, HIPAA is not a valid argument for side stepping other responsibilities that directly involves patient care.

Giving a care giver instructions about what to look for in the patient's condition that might require EMS to be called back is not a HIPAA violation.

Please keep us updated after your meeting.