A documentation specialist is knowledgeable in medical terminology but also demonstrates critical skills of confidentiality and integrity.
Have you ever tried to figure out the words to a song but sometimes just can’t figure out what the performer is singing? For more than a decade, I have been a healthcare documentation specialist. I love to figure these words out; it’s a brain teaser. Some people think it is really boring, but I think of it as someone telling me a story for each person. Who doesn’t enjoy a story? I have met a lot of great physicians, physician assistants, and family nurse practitioners. Each has their own style of telling a story. Sometimes it is short and sweet and sometimes detailed but always interesting.
Because of HIPAA privacy and security rules, the following is an example of my documentation with falsified names and no identifiable information and hopefully a little bit of humor!
January 6, 1888
I Know All About Endocrinology, MD 555 Endocrinology Expert Road Endocrineville, END 00000
Dear Dr. I Know All About Endocrinology:I am referring you Ms. Yule Throid, a very pleasant and active 110-year-old, who has an elevated TSH and thyroid peroxidase antibody that resulted in going to the “Where The Best Food Is” Hospital. She had labs drawn December 25, 1887, which revealed a TSH of 6.00 and TPO antibodies of 125. She was initiated on Synthroid 50 mcg at the beginning of January 1888. After several doses, she developed atypical chest pain and she had to go to “Where The Best Food Is” Hospital. During a rule-out PE protocol, there was note of a thyroid abnormality. Specifically, there are 10 thyroid nodules that require outpatient follow-up and/or biopsy. At this point, Dr. Love Hospfood, who did her evaluation, feels that staying off of thyroid replacement is in her best interest. She has had some leg pain for which she will have a venous Doppler ultrasound prior to this appointment. Therefore, at this juncture, I look forward to your evaluation and strategy for determining whether her nodules and/or thyroid findings require further treatment. Thank you, in advance, for your help with Ms. Throid. Sincerely. ____________________
Miss My Hospeggs, MD MMH/omg Enclosed:
“Where The Best Food Is” Hospital thyroid ultrasound report 01/03/1888
Dr. Love Hospfood endocrine consultation note 01/03/1888
Labs 12/25/1887, 01/03/1888
Venous Doppler ultrasound report (pending)
HIPAA Fun Facts
CFR – The first number (e.g., 45) is the Title of the Code, CFR stands for “Code of Federal Regulations,” and the second number (e.g., 164.312) is the section within that title.
Under 45 CFR 164.312 (a)(2)(i) – Unique User Identification of the HIPAA Security Rule, each and every workforce member should have a unique user identifier when logging into a software program that has access to electronic protected health information (PHI). One of the reasons is that there needs to be an audit trail to track use and disclosure of this information. Individuals have a right to be provided with an account of disclosure of their protected health information based on the HIPAA Privacy Rules.