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)
Subjective (impressions), objective (clinical evidence), assessment (diagnosis), Plans (treatment/management)
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?
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.
the recognition of a disease or injury by symptoms; a critical analysis of the nature of something
attempt to determine which one of several diseases may be producing symptoms
Correction in an electronic medical record.
Patients currently recieving treatment
the records of those patients who have not seen the doctor for six months or longer
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
How long should medical records be kept for an adult?
18 + 3 years
How long should medical records be kept for a child?
If a patient is covered by medicaid or medicare, how long must their files be kept?
Patients should be given an opportunity to claim old records before they are destroyed.
Requests for all medical information must be in _______.
A_______ decides when or if their medical record information should be released.
The form used when a patient decides that they no longer want their medical info shared.
The ________ medical record should never leave the medical facility.
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.
upright shelf files; most popular; resembles bookcase; can be located on the wall
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)
Electronic equipment that brings records automatically to the operator; used in hospitals, clinics, and large practices.
used for quick reference of phone numbers and address patient ledgers, patient index, a library index, an index of surgical tray setup.
Metal framework is used to convert a regular drawer into suspension-folder equipment. A portable file cart can also be used.
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
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.
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
last names are considered ________.
using color as an identifying aid in a filing system to divide the alphabetic sections in the storage system.
used for patients who are transitory.
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
National Health INformation Network.
External hard drive, Full server backup, online back-up system
3 Examples of back up devices for an EMR are?
national archives and Records administration.
American Health Information Management Association
Must be able to rely on the data, the degree in which the information in the database can be trusted.
no piece of info essential to a decision or task should be missing
all users must be able to interpret the data in the health records.
Health information must be entered in to the cart or Database as soon as it is available.
Information must pertain to the person or be useful.
Must be readily available.
Only certain employees should be allowed to access health information, and precautions must be taken to prevent access by intruders.
The record must be legible and must be authenticated properly
Treatments that are used unnecessarily or excessively when they are not needed at all. EX. hysterectomy, typanostomy tubes, and antibiotics.
Having mammograms, pap smears and cervical tests early can help prevent many diseases.
Live discharge rate
number of patients that leave the hospital alive.
national center for health services
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.
a nonprofit organization that provides accreditation to services for healthcare facilities.
any occurrence that could result in patient injury or any type of financial loss to the healthcare facility.
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.
How long does a Dr. have to act on providing the patient with a copy of their health records.
Clinical Laboratory Improvement Amendments
If patients find an error in their medical records, the physician has how many days to correct it?
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?
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.