Kaplan + Sadock's Synopsis of Psychiatry, 11e

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5.3 Psychiatric Rating Scales

Table 5.2-4 Transaction Rule Code Sets

Table 5.2-5 Patient’s Rights under the Privacy Rule

protecting the transmission and confidentiality of patient infor- mation, and all units under HIPAA must comply with such rules. Two rules were finalized in February 2003: the Transaction Rule and the Privacy Rule (see Tables 5.2-4 and 5.2-5). The Transaction Rule facilitates transferring health information effectively and efficiently by means of regulations created by the HHS that established a uniform set of formats, code sets, and data requirements. The Privacy Rule, administered by the Office of Civil Rights (OCR) at HHS, protects the confidentiality of patient information. This means that a patient’s medical infor- mation belongs to the patient and that the patient has the right to access it, with the exception of psychotherapy notes, which are deemed as property of the psychotherapist who wrote them. In 2003, the Privacy Rule was executed. Under the Privacy Rule, there are certain guidelines by which every practice must abide: 1. Every practicemust establishwritten privacy procedures.These include administrative, physical, and technical safeguards that establish who has access to the patient’s information, how this information is used within the facility, and when the informa- tion will and will not be disclosed to others. 2. Every practice must take steps to make sure that its business associates protect the privacy of medical records and other health information. 3. Every practice must train employees to comply with the rule. 4. Every practice must have a designated person to serve as a privacy officer. If it is an individual practice or private prac- tice, this person can be the physician. 5. Every practice must establish complaint procedures for patients who wish to ask or to complain about the privacy of their records. Health care information: The Transactions Rule defines standards and establishes code sets and forms to be used for electronic transaction that involve the following health care information: Claims or equivalent encounter information Eligibility inquiries Referral certification and authorization Claims status inquiries Enrollment and disenrollment information Payment and remittance advice Health plan premium payments Coordination of benefits Code sets: Under the Transaction Rule, the following code sets are required for filing claims with Medicare: Procedure codes American Medical Association Current Procedural Terminology codes Healthcare Common Procedure Coding System codes Diagnosis codes International Classification of Disease, 10th edition, clinical modification, codes Drugs and biologicals National Drug Codes Dental codes Code on dental procedures Nomenclature for dental services Adapted from Jaffe E. HIPAA basics for psychiatrists. Psych Pract Manage Care. 2002;8:15.

Physician must give the patient a written notice of his or her privacy rights, the privacy policies of the practice, and how patient information is used, kept, and disclosed. A written acknowledgment should be taken from the patient verifying that he or she seen such notice. Patients should be able to obtain copies of their medical records and to request revisions to those records within a stated amount of time (usually 30 days). Patients do not have the right to see psychotherapy notes. Physicians must provide the patient with a history of most disclosures of his or her medical history on request. There are some exceptions. The APA Committee on Confidentiality has developed a model document for this requirement. Physicians must obtain authorization from the patient for disclosure of information other than for treatment, payment, and health care operations (these three are considered to be routine uses, for which consent is not required). The APA Committee on Confidentiality has developed a model document for this requirement. Patients may request another means of communication of their protected information (i.e., request that the physician contact them at a specific phone number or address). Physicians cannot generally limit treatment to obtaining patient authorization for disclosure of the patient’s information for nonroutine uses. Patients have the right to complain about Privacy Rule violations to the physician, their health plan, or to the secretary of HHS. APA, American Psychiatric Association; HHS, Department of Health and Human Services. (Adapted from Jaffe E. HIPAA basics for psychiatrists. Psych Pract Manage Care. 2002;8:15.) The OCR at HHS is responsible for making sure that Privacy Rule is enforced; however, it is not clear as to how it will be done. One method expressed by the government is a complaint-driven system in which the OCR will respond to complaints made by patients concerning confidentiality violations or denied access to records, all of which are covered under HIPAA. In such cases, OCR may follow up and audit compliance. The APA’s Committee on Confidentiality, along with legal experts, has developed a set of sample forms. They are part of the APA’s HIPAA educational packet, which can be obtained on the APA web site (www.psych.org/). On the web site, there are also recommendations for enabling physicians to comply with HIPAA. R eferences Dougall N, Lambert P, Maxwell M, Dawson A, Sinnott R, McCafferty S, Springbett A. Deaths by suicide and their relationship with general and psychiatric hospital discharge: 30-year record linkage study. Br J Psychiatry . 2014;204(4). Simon RI. Clinical Psychiatry and the Law. American Psychiatric Pub; 2003.

▲▲ 5.3 Psychiatric Rating Scales

The term psychiatric rating scales encompasses a variety of questionnaires, interviews, checklists, outcome assessments, and other instruments that are available to inform psychiatric practice, research, and administration. Psychiatrists must keep up with major developments in rating scales for several reasons. Most critically, many such scales are useful in psychiatric practice