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.
evalulation and management (E/M)
provider's evaluation of a patient's conditiona and decision on a course of treatment to manage it
process by which a patient authorizes medical treatment after a discussion with a physician
SOAP B OBJECTIVE information
what the provider finds during the examination of the patient; may include data from laboratory tests and other procedures
SOAP D PLAN
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
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
- Procedure / operative reports for simple or complex surgery
- Lab Reports for tests
- Radiology reports for X-Rays
- Forms for: Physicals, immunization records etc..
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
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
- Self pay requests for restrictions
HIPAA Security Rule
law requiring covered entities to extabilish safeguards to protect health information
impermissible use or disclosure of PHI that could pose significant risk to the affected person
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
(FCA) False Claims Act
related law, prohibits submitting a fraudulent claim or making a flase statement or representation in connection with a claim.
causes in which a relator accuses another party of fraud or abuse against the federal government.
HIPAA final enforcement rule
law designed to combine the enforcement procedures for privacy and security standards into a single rule