21st Century Cures Act: What Providers, Healthcare Agencies and EHR Vendors must know

Put your seat belts on, folks. I'm one of several healthcare support agency who are busy preparing additional training on the legalities of documentation. Enforcement provisions of the Cures Act are expected to be announced soon. Documentation will be more important than ever. The reason? The patient will have access to view your documentation. Here is some information

The 1996 Health Insurance Portability and Accountability Act (HIPAA) gave patients the right to view and request corrections to their medical records. This led to the widespread adoption of electronic health records (EHR), patient portals, and smartphone applications, and thus, an increase in patients accessing their medical records electronically.

The 21st Century Cures Act, passed by Congress in 2015, provides regulation on a variety of healthcare concerns, including efforts to make it easier for patients to access their electronic health information (EHI). Enforcement provisions are expected to be announced soon. Hospitals are already preparing for their patients to view their electronic medical information in real-time.

The Cures Act references eight types of clinical notes that must be made available to patients upon request, which include the following:

• Consultation notes  
• Discharge Summary note
• Procedure note
• Progress notes
• Imaging narratives
• Lab report narratives
• Pathology report narratives
• History and physical

Risk management is preparing additional training in sound documentation practices as more and more patients expect instant access to their medical records. Documentation practices that are expected to be addressed are:

• Assume all notes will be read by the patient.
• Complete all documentation promptly.
• Avoid abbreviations that are not easily interpreted by the patient.
• Use of plain language and focus on clarity.
• Do not give 100% control AI tools
• Avoid copying and pasting.
• Before documenting difficult situations, attempt a conversation with the patient or guardian first.

Remember that medical records are used as a key witness in legal proceedings.

Indivirtus AB7 Scribing & RCM is one of the company that follows strict compliance of all such new implimentations. Contact us for Medical Scribing, Medical Transcription, Medical Billing Coding services @ ashok.benial@ab7solutions.com or ashok@indivirtusab7.com for more information.

Contact Number : +1 321 341 7733

Website : www.indivirtusab7.com