Code of Ethics

To: John Smith
From   Anne Carino
Date: May 28, 2010
Re: Audit of Medical Records

Mr. Smith:

Recently I conducted an audit of medical records with a diagnosis of bacterial pneumonia.   I was quite alarmed to find that 65% of all the medical records researched were not supported by the proper documentation.   When I questioned the staff they stated that the Medical Cheild of Respiratory Medicine informed them that “there are other ways to determine bacterial pneumonia other than a lab culture”.   They further stated that there were told that they should just assign the code for bacterial pneumonia.

According to the AHIMA Code of Ethics certain principles need to be strictly adhered to when updating client’s files.   I found numerous violations to these ethics and they are as follows:

1). Advocate, Uphold, and defend the individual’s right to privacy and the doctrine of confidentiality in the use and disclosure of information.
1.1. Protect all confidential information to include personal, health, financial, genetic, and outcome information.

This by law was not followed through because the charts were automatically coded for “bacterial pneumonia” without the proper “outcome information” based on certain tests.

1.2. Engage in social and political action that supports the protection of privacy and confidentiality, and be aware of the impact of the political arena on the health information system. Advocate for changes in policy and legislation to ensure protection of privacy and confidentiality, coding compliance, and other issues that surface as advocacy issues as well as facilitating informed participation by the public on these issues.

This by law was not adhered to because the charts were not in compliance with regards to coding.

2. Put service and the health and welfare of persons before self-interest and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and to the health information...