Kinn's Random Question's Chapter 14-17

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Kinn's chapter 14-17 random questions

The physician or medical facility.

Who owns the patients medical records?

Paper and electronic

What two types of records are there?

electronic medical record

Electronic health record is also known as?

Source oriented records

traditional record, each discipline makes notations in a separate section, information about a particular problem distributed throughout the record, NARRATIVE CHARTING USED

Problem oriented medical records

A system of charting that is organized according to each medical problem. (Database, problem list, treatment plan, progress notes)

SOAP

Subjective (impressions), objective (clinical evidence), assessment (diagnosis), Plans (treatment/management)

CHEDDAR

chief complaint, history of present illness examination, details, drugs and dosages, assessment, return visit information or referral.

POMR (patient oriented medical records)

Soap is most often used in which type of medical record?

Patient demographics

basic information such as name, address, telephone number, gender, date of birth, social security number, and employment information.

Patient's family history

information regarding the health of members of the patient's family, includes any diseases, illnesses, and cause of death.

Patient's social History

It provides information about the patients lifestyle. (smoking, drinking, drugs, marital status)

Patient's chief complaint

a statement of the patient's symptoms, nature, and duration of pain. Should include when symptoms were first noticed, patients opinion about the illness, remedies tried, was it a previous condition, other medical treatment for the same problem.

Scale of 1-10

What should a patient use to describe the level of pain that they are experiencing.

Diagnosis

the recognition of a disease or injury by symptoms; a critical analysis of the nature of something

Differential Diagnosis

attempt to determine which one of several diseases may be producing symptoms

addendum

Correction in an electronic medical record.

active files

Patients currently recieving treatment

inactive files

the records of those patients who have not seen the doctor for six months or longer

closed files

containing files of pts who have died, moved, or terminated the relationship

perpetual transfer method

a method of transferring records continuously from active to inactive storage areas whenever they are no longer needed for reference

10 years

How long should medical records be kept for an adult?

18 + 3 years

How long should medical records be kept for a child?

10 years

If a patient is covered by medicaid or medicare, how long must their files be kept?

True

Patients should be given an opportunity to claim old records before they are destroyed.

writing

Requests for all medical information must be in _______.

patient

A_______ decides when or if their medical record information should be released.

revocation form

The form used when a patient decides that they no longer want their medical info shared.

Original

The ________ medical record should never leave the medical facility.

shelf files

Which type of cabinet requires the least amount of aisle space?

rotary circular files

A SMALL DESKTOP FILE DESIGNED TO ROTATE, THUS PERMITTING THE USE OF BOTH SIDES OF AN INDEX CARD.

lateral files

upright shelf files; most popular; resembles bookcase; can be located on the wall

compactable files

They are mounted on tracks in the floor and the units slide along the tracks so that access is gained to needed records. (Used in tight spaces)

Automated files

Electronic equipment that brings records automatically to the operator; used in hospitals, clinics, and large practices.

Card Files

used for quick reference of phone numbers and address patient ledgers, patient index, a library index, an index of surgical tray setup.

Special items

Metal framework is used to convert a regular drawer into suspension-folder equipment. A portable file cart can also be used.

label

a necessary filing device, used to identify each shelf, drawer, divider guide, and folder.

conditiong of papers

removing all pins, brads and paperclips; stapling related papers together and

Releasing

some mark is placed on the file showing that it is ready for filing.

indexing and coding

deciding where to file the letter or paper and placing some indication of the decision on the paper.

sorting

grouping by class or kind or size, in sequence.

storing and filing

items faced up top edge to the left with most recent date at front of the folder

first

last names are considered ________.

color coding

using color as an identifying aid in a filing system to divide the alphabetic sections in the storage system.

temporary files

used for patients who are transitory.

NAHIT

National alliance for Health information technology

All capabilities of EMR System

specialty software, appt. scheduling, appt. reminder,prescription writer, medical billing system, charge capture eligibility verification, referral management, laboratory order integration, patient portal

NHIN

National Health INformation Network.

External hard drive, Full server backup, online back-up system

3 Examples of back up devices for an EMR are?

FR

Federal Register

NARA

national archives and Records administration.

AHIMA

American Health Information Management Association

Validity

Accuracy

Reliability

Must be able to rely on the data, the degree in which the information in the database can be trusted.

Completeness

no piece of info essential to a decision or task should be missing

Recognizability

all users must be able to interpret the data in the health records.

Timeliness

Health information must be entered in to the cart or Database as soon as it is available.

Relevance

Information must pertain to the person or be useful.

accessibility

Must be readily available.

Security

Only certain employees should be allowed to access health information, and precautions must be taken to prevent access by intruders.

Legality

The record must be legible and must be authenticated properly

Overused treatments

Treatments that are used unnecessarily or excessively when they are not needed at all. EX. hysterectomy, typanostomy tubes, and antibiotics.

Underused treatments

Having mammograms, pap smears and cervical tests early can help prevent many diseases.

Live discharge rate

number of patients that leave the hospital alive.

N.C.H.S.

national center for health services

NCHS

Who is the primary provider of the health information statistics used to guide actions and policies affecting the health of the American public.

Total Quality Management

control activities based on the leadership of top level management and supported by the involvement of all employees and departments, from planning and development to sales and service.

Joint commission

a nonprofit organization that provides accreditation to services for healthcare facilities.

RISK

any occurrence that could result in patient injury or any type of financial loss to the healthcare facility.

COBRA

Consolidated Omnibus Budget Reconciliation Act

HIPAA TITLE I

Insurance Reform; It is to provide continuous insurance coverage for workers and their insured dependents when they change or lose jobs.

HIPAA TITLE II

Administrative Simplification; focus on the health care practice setting and aim to reduce administrative costs and burdens.

30 Days

How long does a Dr. have to act on providing the patient with a copy of their health records.

CLIA

Clinical Laboratory Improvement Amendments

60 days

If patients find an error in their medical records, the physician has how many days to correct it?

Business Associates

Both covered entities and ________ __________ can discuss a patient's bill with a person other than the patient to obtain reimbursement.

Once per year

How many times can a patient receive health records for free?

ID

Always ask for __ when patients come to pick up records

Name and D.O.B

Always ask patient for ____ and ___ when calling a patient back.

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