41 terms

Chapte 2


Terms in this set (...)

failure to use professional skill when giving medical services that results in injury or harm
recording of a patients health in status in medical record
medical standards of care
state-specified measures for the deivery of health care
Medical records
medical records are charts created by physicians and other providers,these are stored on paper or electronically
Documenting encounters with providers
every patient encounter the face to face meeting between a patient and a provider in a medical office
SOAP Format has for parts
medical ins,specialists work with a member of methods that are used to organize patient medical record.the most common format is called a problem-oriented medical record (POMR)
SUbjective,objective,Assessment and Plan
the information is what the patient names as the problems or complates
the information is what the provider finds during the examination of the patient,it may include data from laboratory test and other procedures
is called the impression or conclusion,is the provider diagnosis or diagnoses
called advice or recommendation is the course of treatment for the patient such as surgery,medications or other test,including necessary patient monitoring, follow-up nand instructions to the patient
evaluation and management
providers evaluation of a patients condition and decision on a course of treatment to manage it
Termination of the provider patient relationship
If a patient wishes to be released from a physicians care the provider documents this fact and any part of the treatment plan that was still underway at the time of treatment
electronic health record (EHR)
computerized lifelong health care record with data from all sources
electronic medical record (EMR)
computerized record of one physicians encounters with a patient
Health care regulation
to protect consumers,health both federal and state governments pass laws that effect the medical services that must be offered to patients
Federal and state regulation
the main federal government agency responsible for health care is the Centers for Medicaid and Medicare Services know as CMC (formeerly the health care Financing Administration or HCFA)
Centers for medicare and medicaid services
federal agency that runs medicaid,medicare clinical laboratories and other government health programs
health insurance portability accountability act(HIPAA)of 1996
federal act with guidelines for standardizing the electronic data interchange of administrative and financial transactions exposing fraud and abuse and protecting PHI
Health information technology for economic and clinical health ((HITECH) law promoting the adoption and use of health information technology
Covered Entities and Business Associates
patients medical records-the actual progress notes,report and other clinical materials are legal documents that belong to the provider who created them,but the provider cannot withhold information in the records unless providing it would be detrimental to the patients health.the information belongs to the patient.
Electronic data interchange
system to system exchange of data in a standardized format
Three Administrative Simplification Provisions
1 HIPAA Privacy rule-the privacy requirements simlification provisions information
2 HIPAA Security rule The secrity requirements state the administrative technical and physical safeguards that are required to protect patients health information
3 HIPAA Electronic Transaction and code sets standards these standards require every provider who does business electronically to use the same health care transactions,code sets and identifiers
covered entity (CE)
health plan clearinghouse or provider who transmits any health information in electronic form
company that converts nonstandard transactions into standard transaction and transmit the data to health plans and the reverse procedure
Business associate (BA)
person or organization that performs a function or activity for a covered entity
HIPAA Privacy rule
law regulating the use and disclosure of patients protected health information (PHI)
protected health information (PHI)
individually identifiable health information transmitted or maintained electronic media
Treatment payment and health care operations (TPO)
legitimate reasons for the sharing of patients protected health information without authorization
Notice of privacy practics
covers entities must give each patient a notice of privacy practice at the first contact or encounter
document signed by a patient to permit release of medical information,health plans system of approving payment of benefits for appropriate services
there are a number of exceptions to usual rules for release
1 court orders
2 workers compensation cases
3 research
4 self-pay requests for restrictions
order of a court for a party to appear and testify
Subpoena ducestecum
order of a court directing a party to appear testify and bring specified documents or items
impermissible use or disclosure of phi that could pose significant risk to the affected person
Breach notification
document notifying an individual of a breach
HIPAA Electronic health care transactions and code sets (tCS)
governing the electronic exchange or health information
Health care and fraud and abuse control program
government program to uncover misuse of funds in fedreal health care programs
actions that improperly use anothers resources
compliance plan
consistent writen policies and procedures
appointment of a compliance officer and committee
disciplinary systems
auditing and monitoring
responding to and correcting errors
federal false clams
are based on the guideline that providers who knew or should have known that a claim for service was false can be held liable
errors and omissions
Medical liability insurance medical liability cases for fraud often resuit in lawsiuts
Employer identification record
the employer identifier is used when employers enroll or disenroll employees,in a health plan make premium payments on behalf of their employees