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Duty of confidentiality

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During a High Court proceeding in Kuala Lumpur, Malaysia the presiding Judicial Commissioner proclaimed that the bedrock of society’s belief would be shattered.if the medical profession do not uphold a patient’s information safe from unauthorised disclosure. This was reported on 31 October 2013 in the local English daily newspaper, The Star.

In his judgement he called upon medical professionals and hospitals to take the duty of confidentiality very seriously since they had a duty to ensure patients’ medical information were safeguarded and not disseminated in any unauthorised manner.

In passing sentence, the court then ordered a director of the Medical Centre and two others to pay RM400,000 to a community leader for revealing his psychiatric medical records. The plaintiff claimed that the documents were circulated to the residents of his community to humiliate him and which implied he was a lunatic, of unsound mind and unfit to hold positions in the NGOs. He sued for costs and other relief deemed fit by the court for negligence and failure on the part of the Medical Centre to safeguard his personal documents, and the defendants for exemplary and punitive damages – to me it is clear that the defendants’ wilful acts were malicious and wanton.

Nevertheless, I  find It is not clear from the daily’s article how the medical records landed in the hands of the two defendants who had distributed documents containing the personal particulars and medical records of the plaintiff’s treatment to other residents of the community as well as when they started to tell the residents that the documents showed that the plaintiff was a lunatic.

The moral of the story is to quote from Hillary Clinton, “In almost every profession – whether it’s law or journalism, finance or medicine or academia or running a small business – people rely on confidential communications to do their jobs. We count on the space of trust that confidentiality provides. When someone breaches that trust, we are all worse off for it.”

References:

  1. Nation, The Star Online, ‘Four pay price for revealing medical records’, viewed 31 October 2013 <http://www.thestar.com.my/News/Nation/2013/10/31/Four-pay-price-for-revealing-records-Community-leaders-medical-documents-were-distributed-to-residen.aspx>

End-of-life issues, what you need to document in the medical record

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Image credit : National Institutes of Health, USA

Image credit : National Institutes of Health, USA

Assessment findings guide the care and services to be provided by all the patient’s health care practitioners, including the doctor and/or nurse. The findings are then normally documented in the patient’s medical record.

Likewise, reassessment by a doctor are also documented in the patient’s medical record. I had posted about the need to document reassessment into the patient’s medical record as defined in organisation policies and procedures for thirteen (13) situations in the post Reassessment of all patients and results are always entered in their medical records (this link will open in a new tab of your current browser window), the thirteenth situation been when dying patients and their families are assessed and reassessed according to their individualised needs by evaluating and managing their symptoms and preventing complications to the extent reasonably possible in the care of these dying patient to optimize his or her comfort and dignity.

When patients are at the end of life, these dying patients including their families or indeed anyone else actually connected with the patient are then assessed and reassessed to identify the patients’ and families’ needs, i.e end-of-life issues. Assessments and reassessment are carried out to evaluate the patient’s condition such as symptoms of nausea and respiratory distress and to identify factors that seem to alleviate or exacerbate the physical symptoms, the patient’s current symptom management and the patient’s response.

Thus the medical record of a dying patient should contain documentation on symptoms like nausea and respiratory distress and whatever factors that are alleviating or exacerbating these physical symptoms.

Also to be found in the medical record of a dying patient will be documentation on assessments on both the patient’s and family’s individualised needs including evaluations to record the following :

  1. spirituality – it would be much more difficult to anticipate the spiritual needs of a patient and family from a culture unfamiliar to you, so better understand what is the patient’s and the surrounding family members’ dominant religion and views regarding the meaning and purpose of life and, as appropriate, any involvement to a religious group and what are their spiritual concerns or needs, such as despair, suffering, guilt, or forgiveness, thus the need to work within the patient’s and the patient’s family cultural belief system by hearing the patient and his or her family and the patient’s daily experiences; culturally based care i.e transcultural nursing according to Madeleine Leininger who was a nursing theorist, nursing professor and developer of the concept of transcultural nursing, contributes to healing (health), well-being, and helping patients who face dying or death
  2. their psychosocial status, such as family relationships, the adequacy of the home environment if care is provided there, coping mechanisms
  3. the patient’s and family’s reactions to illness since the patient will experience significant loss as a result of the health alteration when recovery from illness is incomplete; as a result many people (patient and/or family) may direct that anger towards health-care personnel because they have no control over the situation already as the loss begins to sink in but when finally, the patient and family come to terms with the loss, they will begin making plans for the future
  4. the need for support or respite services with the challenges of caring for the dying by the caregiver(s)
  5. the patient’s need or request from the patient’s family for, an alternative setting or level of care
  6. any survivor risk factors, such as family coping mechanisms and the potential for pathological grief reaction

The above documentation requirements in a medical record of a dying patient are required more so if you as a Health Information Management (HIM) / Medical Records (MR) practitioner manage such medical records in a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, when your hospital will need to fully comply with the JCI Standard AOP.1.9 which states that “Dying patients and their families are assessed and reassessed according to their individualized needs.” The three (3) Measurable Elements of Standard AOP.1.9 will be measured through the Medical Record Review Tool (MMRT).

Medical records documentation of dying patients is not just to comply with an accreditation body like the JCI.  The filing of the medical record about end-of-life concerns about the amount of information which might be submitted within the medical record which will then be subject to scrutiny irrespective of whether that scrutiny included any authorised investigatory agency. Although a doctor may believe  that he or she may not have done nothing wrong, he or she will fear the process of investigation of deaths (Stephen 2012), under a death reporting system.

As a diversion to end-of-life issues, medical records of a not-dying patient, Hilly Boscher from the Netherlands is worthy of mention when in the Chabot case (Stephen 2012), a psychiatrist named Chabot helped this patient to die who was NOT terminally ill i.e NOT a dying patient. In this case, she (Hilly) had been suffering from grief as a result of losing both of her children. Dr Chabot diagnosis was :  ‘an adjustment disorder consisting of a depressed mood, without psychotic signs, in the context of a complicated bereavement process’. Hilly had refused all anti-depressants and bereavement counselling. However, Chabot was not convicted by the Dutch Supreme Court on the ground that (Stephen 2012 p.288) “there was no requirement that suffering is terminal or physical”.  My point is, seven (7) other psychiatrists had examined her medical records and had agreed with Chabot’s diagnosis, so do you agree that there is the greater need for greater detail in medical records documentation in the case of a dying patient?

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
  3. Stephen, WS 2012, End-of-Life Decisions in Medical Care Principles and Policies for 
  4. Regulating the Dying Process, Cambridge University Press, Cambridge, United Kingdom
  5. Pamela, MS & Linda, N 2010, Communication for nurses : how to prevent harmful events and promote patient safety, F. A. Davis Company, Philadelphia, PA, USA

WHO-FIC Network Annual Meeting 2013 – Beijing, People’s Republic of China

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A Health Information Management (HIM) / Medical Records (MR) practitioner reader of this website-blog will surely be familiar and knowledgeable of The International Classification of Diseases (ICD) that covers death and disease, two main parameters of health and the health system.

Perhaps many  HIM / MR practitioners may still not know that the ICD is one other reference classification which belongs to the World Health Organization Family of International Classifications (WHO-FIC)  Likewise, ICF (the International Classification of Functioning and Disability) and ICHI (International Classification of Health Interventions) are also reference classifications which belong to the WHO-FIC.

I think it is appropriate for any HIM / MR practitioner to be aware of developments of WHO classifications such as the ICD.  In this post, I like to share in this post of what is already available at the WHO website about the 2013 Annual Meeting of the International Network of WHO-FIC Collaborating Centres (WHO-FIC 2013) which will be held at the Empark Grand Hotel, in Beijing, China, from 12 to 18 October 2013. This year’s theme is: “Universal Health Coverage: Information and Innovation”. The reader can view detailed information about the meeting venue, accommodation and registration available on the meeting website at this link (this link will open in a new tab of your current browser window).

Since participation to this meeting is by invitation only, I like to suggest – since HIM / MR practitioner readers will already be familiar with ICD-10 but need to be aware of the ICD-11 revision, to focus and follow the progress and developments in ICD-10 and ICD-11 to be presented when the WHO-FIC Council meets in Beijing soon to review progress in relation to the strategic work plan of the WHO-FIC network and plan for the future. Please click on these links below (each of these links will open in a new tab of your current browser window) to know and learn the progress and developments in ICD-10 and ICD-11 :

progress and developments in ICD-10

progress and developments in ICD-11

References:

  1. WHO-FIC Network Annual Meeting 2013 – Beijing, People’s Republic of China, Classifications, The World Health Organisation (WHO), viewed 3 October 2013, <http://apps.who.int/classifications/network/meeting2013/en/>
  2. WHO-FIC Network Annual Meeting 2013, 2013 WHO-FIC Network, The World Health Organisation (WHO), viewed 3 October 2013, <http://www.whofic2013.org/register/toFrontPage.do>

APDC: Relevant conditions and scenarios that affects the eyes – Part 1

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ICD-10-book-cover-for-APDC-series-labelIn everyday International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version 2010 coding, answers to your coding questions can be found by reviewing or referring to the ICD-10 coding books. However, in this post I like to highlight some key documentation elements for the eye and adnexa.

On of the first things to take note when coding diseases of the eye and adnexa is when a Health Information Management (HIM) / Medical Records (MR) practitioner coder will find codes with the letter H shared among two chapters of the ICD-10.

I am sure a HIM / MR practitioner must already know that the ICD-10 classification is divided into 21 chapters, the first character of any ICD-10 code is a letter, one letter is generally associated with a particular chapter, except for some letters like the letter H will be found among codes in both Chapter VII, Diseases of the eye and adnexa and Chapter VIII, Diseases of the ear and mastoid process.

I shall not be detailed in this post but I intend to lead a discussion of the various diseases, disease processes, disorders, injuries, and conditions, some diagnostic statements related to diseases of the eye and adnexa.  I shall confine to infectious diseases of the eye, neoplasms of the eye, eyelid disorders, the lacrimal system, the conjunctiva, and end with the sclera, cornea, iris, and ciliary body.

One of the common diseases of the eye and adnexa are due to infections of the eye. I can quickly relate to viral conjunctivitis, eye infections that often involves the conjunctiva that are reported with codes from Chapter 1 Certain Infectious and Parasitic Diseases.  My experiences have shown that only a few eye infections are reported with codes from Chapter 1 while I think the vast majority of eye infections are reported with codes from Chapter 7 – Diseases of the Eye and Adenxa.  Do take note of some types of conjunctivitis that are reported with a single code from Chapter 1.

All parts of the eye may be affected by neoplasms. which may be primary, secondary (metastatic) or benign. Coders then will need to rush into Chapter II – Neoplasms and look up for example, the malignant neoplasms of eye and adnexa under ICD-10 code C69.

Symptoms that include eyelid tenderness or pain, increased tearing, and sensitivity to light are reported as chalazion, when the Meibomian gland (tiny oil gland in the eye) duct is blocked. Blepharitis is an inflammation of the eyelash follicles, along the edge of the eyelid. Entropions, when there is a turning inward of the eyelid so that the eyelashes rub against the surface of the eye can irritate the eye and in severe cases may cause corneal abrasion, ulcer, or scarring. Entropions may be acquired or congenital.  Acquired entropions and ectropions are two conditions that occurs primarily in the elderly (senile populations). Coding chalazion, blepharitis, but less of entropions and etropions (you probably get to code these two if you work at a hospital or eye centre with an eye speciality) are some common diagnoses I have encountered.

Look out for subtle differences in coding for example when coding chronic enlargement of the lacrimal gland as against chronic dacryadenitis. When dacryadenitis is reported alone, then assign code to H04.0 Chronic enlargement of the lacrimal gland, but assign code H04.4 when chronic dacryadenitis is reported.

Several conditions affect the sclera, cornea, iris and ciliary body which are structures in the anterior chamber of the eye. I can think of the cornea which is subject to inflammatory conditions such as corneal ulcer and keratitis, and conditions commonly affecting the iris and ciliary body which include inflammatory conditions such as iritis, iridocylitis, or cyclitis, and even cysts which may form in the iris or ciliary body. Disorders of sclera, cornea, iris and ciliary body are found in the block H15 to H22.

In the next instalment, I shall discuss about cataracts which is the single very common condition affecting the lens, conditions affecting the choroid and retina, moving on to glaucoma which is actually a group of diseases of the eyes characterised by damage of the optic nerve, and end with some conditions affecting the vitreous body and globe.

References:

  1. Gerard, JT & Bryan, D 2012, Principles of Anatomy & Physiology, 13th edn, John Wiley & Sons, Inc, New Jersey, USA
  2. Michael, M & Valerie, OL 2012, Human anatomy, 3rd edn, The McGraw-Hill Companies, Inc., New York, USA
  3. Phillip, T 2012, Seeley’s principles of anatomy & physiology, 2nd edn, The McGraw-Hill Companies, Inc., New York, USA
  4. World Health Organization 2011, Volume 1 Tabular list, International Statistical Classification of Diseases and Related Health Problems 10th Revision, 2010 edn, Geneva, Switzerland

APDC: Relevant conditions and scenarios that affects the eyes

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ICD-10-book-cover-for-APDC-series-labelIn the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version 2010, the Chapter VII: Diseases of the eye, adnexa is dedicated specifically for diseases of the eye and adnexa.

In this first part and the next post(s) dedicated to relevant conditions and scenarios that affects the eyes, I like to present most (if not all) the relevant conditions and scenarios that affects the eyes, which are considered as the most complex of the four special sense organs.

The relevant conditions and scenarios that affects the eyes are those affecting the structures that are specifically related to vision as well as accessory structures. The eyeball, optic nerve, and brain are the structures related to vision typically activated by a stimulus, such as light, in the external environment which is detected by the cells of the eye, thereby sending electrical impulses to the visual center and other parts of the brain. In addition to allowing light perception, the eye performs other tasks such as color differentiation and depth perception. The accessory structures include the eyebrows, eyelids, ocular muscles, and lacrimal glands.

As you can see from the anatomy of the human eye in the image below, the eye is divided into three layers: the fibrous tunic (also referred to as the scleretic coat – the external layer of the eye divided into two parts, the sclera, also called the white of the eye, and the anterior cornea), vascular tunic (also referred to as the uvea or choroid coat – this is the middle layer of the eye and structures contained in the vascular tunic include the choroid, ciliary body and iris), and lastly the retina (the inner layer of the eye, which is composed primarily of nervous tissue including various types of cells for the primary function of image formation).

human-eye-anatomy-[Converted]

As I am not a eye care trained nurse nor an ophthalmologist to provide a full length description of conditions and scenarios  affecting the human eye (nonetheless it is pointless doing so, when one can gain such knowledge from any good Anatomy and Physiology academic textbook), and so I shall confine myself to my perspective of past coding experiences and knowledge of common and top conditions and scenarios affecting the human eye that Health Information Management (HIM) / Medical Records (MR) practitioners may also encounter in their everyday coding duties.

If a HIM / MR practitioner reader was to examine closely the Chapter VII, he or she will find (to my best knowledge) the following ICD-10 categories relevant to the eye and adnexa with conditions and scenarios which demand eye care:

C69.*** Malignant neoplasm

D31.*** Benign neoplasms

H01.***: Conditions of the eyelid

H02.***: Entropions

H04.***: Conditions of the lacrimal system

H05.***: Conditions of the orbit

H10.***: Conjunctival conditions

H15.***: Conditions of the sclera

H16.***: Keratoconjunctivitis

H17.***: Conditions of the cornea

H18.***: Keratopathies

H20.***: Conditions of the iris

H21.***: Disorders of iris and ciliary body

H25.***: Cataracts

H26.***: Cataracts, other

H27.**: Conditions of the lens

H30.**: Chorioretinal conditions

H31.***: Conditions of the Choroid

H33.**: Conditions of the retina

H34.***: Retinal occlusions

H35.***: Retinal changes

H40.***: Glaucoma

H43.***: Vitreous codes

H44.***: Disorders of vitreous body and globe

H44.6**: Unspecified retained (old) intraocular foreign bodies

H47.***: Neuropathies

H51.***: Convergence disorders

H52.***: Refraction Disorders

H53.***: Amblyopia/visual field defects

H54.***: Blindness

H55.***: Nystagmus

H57.***: Pupillary Disorders and ocular pain

H59.***: Disorders following Surgery

R**.***: Sign and symptom codes (headache, weakness, malaise, fever, shock)

R00 – R99: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified as in the case of abnormal results of function studies of peripheral nervous system and special senses, e.g abnormal electroretinogram [ERG]

S**.***x: S Codes – injury, poisoning and certain other consequences of external causes, involving injury of eye and orbit

T**.***x: T Codes – e.g. FB in cornea

T74.***: adult and child abuse, neglect and maltreatment, using additional code, if desired, to identify current injury to the eye and adnexa (if any)

T36 -T50: Poisoning by drugs, medicaments and biological substances: poisoning by topical agents primarily affecting skin and mucous membrane and by ophthalmological, otorhinolaryngological and dental drugs e.g ophthalmological drugs and preparations as in the case of eye anti-infectives

X00 – X99: External causes of morbidity from e.g exposure to smoke, fire and flames

V01 – V99: External causes of morbidity due to transport accidents

Z00-Z99: Factors influencing health status and contact with health services, e.g examination of eyes and vision

The above list is inclusive of the nine (9) block of codes for coding conditions and scenarios related to eye and adnexa ranging from H00 to H59 in Chapter VII. However, the list also includes codes which are not classifiable to Chapter VII, as you as the interested reader can figure out from the exclusion note right at the beginning of this chapter. Attention is also required  when asterisk categories for this chapter are provided also at the beginning of this chapter for several disorders and glaucoma in diseases classified elsewhere.

Thus, HIM / MR practitioners need to be alert to coding correctly for eye care when they encounter conditions and scenarios  affecting the human eye which were not reported by any eye care speciality, signs and symptoms not specifically eye care, injuries and accident to the eye, top peripheral codes applicable to eye care such as diabetes and hypertension, Late Effect Codes listed as “Sequela” and foreign body in the eye(s).

In the next part, I plan to present a variety of diseases, disorders, injuries, and other conditions involving the eye and adnexa. I will present some images to present the anatomy and physiology of more commonly encountered conditions involving the eye and adnexa, expanding from there to provide a better understanding regarding the part of the eye or adnexa affected and how these conditions affect function.

Following the images of the more commonly encountered various diseases, disease processes, disorders, injuries, and conditions, I will of course present the ICD-10 codes and any coding concepts and guidelines relevant to Chapter VII.

References:

  1. Gerard, JT & Bryan, D 2012, Principles of Anatomy & Physiology, 13th edn, John Wiley & Sons, Inc, New Jersey, USA
  2. Michael, M & Valerie, OL 2012, Human anatomy, 3rd edn, The McGraw-Hill Companies, Inc., New York, USA
  3. Phillip, T 2012, Seeley’s principles of anatomy & physiology, 2nd edn, The McGraw-Hill Companies, Inc., New York, USA
  4. World Health Organization 2011, Volume 1 Tabular list, International Statistical Classification of Diseases and Related Health Problems 10th Revision, 2010 edn, Geneva, Switzerland