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Medical Record

file containing the documentation of a patient's medical history and related information


failure to use professional skill when giving medical services that results in injury or harm.


recording of a patient's health status in a medical record

medical standards of care

state-specified performance measures for the delivery of health care


office visit between a patient and a medical professional

evalulation and management (E/M)

provider's evaluation of a patient's conditiona and decision on a course of treatment to manage it

informed consent

process by which a patient authorizes medical treatment after a discussion with a physician


Subjective; Objective; Assessment; Plan


What patient names as the problems or compaints

SOAP B OBJECTIVE information

what the provider finds during the examination of the patient; may include data from laboratory tests and other procedures


also called impression or conclusion, is the provider's diagnosis or diagnoses.


also called advice or recommendations; the course of treatment for the patient. Tests, surgery,follow-up etc..

History and Physical Examination

A complete history and physical (H&P) is documented with four types of information
1) chief complaint
2) the history and physical exam
3) the diagnosis
4) the treatment plan

Progress Report

SOAP update

Discharge Summary

prepared during patient's final visit for a particular treatment plan or hospitalization. They include:
- Final Diagnosis
- Comparisons of objective date per patient's statements
- Whether goals were achieved
- reason for and date of discharge
- patient's current condition, status and final prognosis
- discharge instructions or special needs / meds.

Procedural Services Documentation / Notes

Several Are:
- Procedure / operative reports for simple or complex surgery
- Lab Reports for tests
- Radiology reports for X-Rays
- Forms for: Physicals, immunization records etc..

Termination Letter

Letter from provider discharging patient ending relationship

EHR - Electronic Health Record

computerized lifelong health care record with data from all sources

EHR - Advantages over paper records

-Immediate access to health information.
- Computerized physician order management: physicians can enter orders for prescriptions, tests, services.
- Clinical decision support: thru medical websites etc..
- Automated alerts & reminders
- Electronic communication & connectivity
- Patient support - i.e. mychart
- Administation & reporting
- Error reduction

EMR - Electronic medical record

computerized record of one physician's encounters with a patient - serve as physician's legal record of patient care

(CMS) Centers for Medicare & Medicaid Services

Federal agency that runs Medicare, medicaid, clinical laoratories and other government health programs

(HIPAA) Health Insurance Portability and Accountability Act of 1996

Federal act with guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse, and protecting PHI

(ARRA) American Recovery and Reinvestment Act of 2009

Law with provisions concerning the standards for the electronic transmission of health care data

(HITECH) Health Information Technology for Economic and Clinical health Act

Law promoting the adoption and use of health information technology

(TPO) Treatment, payment and health care operations

legitimate reasons for the sharing of patients' protected health information without authorization

minimum necessary standard

principle that individually identifiable health information should be disclosed only to the extent needed.

(DRS) designated record set

covered entity's records that contain protected health information (PHI); for providers, the medical / financial patient record


1) document signmed by a patient to permit release of medical information
2) health plan's system of approving payment of benefits for appropriate services

(NPP) Notice of Privacy Practices

description of a covered entity's principles and procedures related to the protection of patients' health information


allows patients to request an accounting of all disclosures for the past three years if their PHI is stored in an EHR


order of a court for a party to appear and testify

Subpoena duces tecum

order of a court directing a party to appear, testify, and bring specified documents or items

Exceptions to Rules for Release of info:

- Court orders
- Workers' comp. cses
- Statutory reports
- Research
- Self pay requests for restrictions

De-itentified health information

medical data from which individual identifiers have been removed

HIPAA Security Rule

law requiring covered entities to extabilish safeguards to protect health information


method of converting a message into encoded text


impermissible use or disclosure of PHI that could pose significant risk to the affected person

Breach notification

document notifying an individual of a breach - must include:
1) description of what happened & date
2) description of types of unsecured PHI that were involved (i.e. full name, SS#, DOB, state, address etc)
3) steps that should be taken for ind. to protect himself
4) investigation update
5) contact info. for individuals to ask question

(TCS) HIPAA Electronic Health Care Transactions and Code Sets

Rule governing the electronic exchange of health information

HIPAA National Identifiers

Identification systems for employers, health care providers, health plans, and patients

(EIN) Employer Identification Number

used when employers enroll or disenroll employees in a health plan or make premium payment to plans on behalf of their employees. Issued by IRS

(NPI) National Provider Identifier

standard for the ID of providers when filing claims and other transactions.

Health Care Fraud and Abuse Control Program

government program to uncover misuse of funds in federal health care programs

(OIG) Office of the Inspector General

gpvernment agency that investigates and prosecutes fraud

(FCA) False Claims Act

related law, prohibits submitting a fraudulent claim or making a flase statement or representation in connection with a claim.

Qui tam

causes in which a relator accuses another party of fraud or abuse against the federal government.


person who makes an accusation of fraud or abuse


intentional deceptive act to obtain a benefit; i.e. to bill when the task was not done


Actions that improperly use another's resources; i.e. to bill when it was not necessary.

HIPAA final enforcement rule

law designed to combine the enforcement procedures for privacy and security standards into a single rule

(OCR) Office for Civil Rights

government agency that enforces the HIPAA Privacy Act


formal examination of a physician's records

Respondeat superior

doctrine making empoyers responsible for employee action

compliance plan

medical pratice's written plan for complying with regulation

(PHI) Protected Health Information

Individually identifiable health information that is transmitted or maintained by electronic media

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