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Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication. If written correctly, notes will support the doctor about the correctness of treatment.
Medical records also serve as the basis for determining if a particular procedure or treatment is medically necessary and, therefore, covered by the workers' compensation insurance. Records of your client's medical history are also important because these show if your client has pre-existing health conditions.
When an error is made in a medical record entry, proper error correction procedures must be followed. Draw line through entry (thin pen line). Make sure that the inaccurate information is still legible. Initial and date the entry.
Copies of medical reports and bills Maintaining copies of your medical reports and bills is critical for a variety of reasons. For instance, your medical reports from an emergency room can help corroborate and injured workers' account of an accident, as well as what body parts were injured as a result of the accident.
Medical history is very important in a workers' compensation case, and injured workers have to disclose their entire medical history to the workers' compensation physician to avoid complications during the medical claims review stage.
The Privacy Rule is not intended to impede the flow of health information to those who need it to process or adjudicate claims, or coordinate care, for injured or ill workers under workers' compensation systems.
HIPAA does not apply to workers' compensation matters because the federal statute exempts workers' compensation from its coverage.
Illegal activities: Employee injuries due to illegal activities at the worksite are not covered by an organization's workers' compensation insurance policy. Policy violations: Workers' comp does not cover employees who are injured while violating company policies, procedures and protocols.