Chapter 23, Health Records and Health Information Management & HIPAA
System for Medicare patients by which a predetermined level of reimbursement is established before the services are provided. Based on Geographic and demographic data.
Classification system of patients based on the International Classification of Diseases, 9th edition, Clinical Modification codes for diagnoses, current procedural terminology evaluation and management codes, and procedure codes, age, sex, and visit disposition; used for reimbursement for health care provided in the hospital outpatient setting.
System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay (reimbursement based on diagnosis groups and statistics. in the US for physician reimbursement)
Radiologic codes between 70010 to 79999 (ex. Chest x-ray= 71010).
Professionals who are technical experts in health data collection, analysis, monitoring, maintenance, and reporting activities in accordance with established data-quality principles, legal and regulatory standards, and professional best practice guidelines.
Professionals who posses the expertise to develop, implement, and/or manage individual aggregate, and public health care data in support of patient safety and privacy, as well as the confidentiality and security of health information.
Organization that accredits hospitals and other health care institutions in the United States.
Accreditation program of the American Osteopathic Association that accredits health care facilities in the United States.
2. Medical History
3. Examination findings
4. Diagnostic and therapeutic orders
5. Clinical observation (with results of therapy)
6.Diagnostic and therapeutic procedures with results
7. Informed consent
8. Conclusion at termination of hospitalization
Generally considered as the portal through which clinicians access a patient’s health record, order treatments or therapy, and document care delivered to patients; allows providers to gather multiple types of data about a patient (clinical, financial, administrative, and research.)
“No order, no procedure!”
Comprehensive listing of medical terms and codes for the uniform designation of diagnostic and therapeutic PROCEDURES; used in the U.S. for coding for physician reimbursement.
Radiologic codes between 70010 to 79999 (Chest x-ray: 71010).
Notice given to a patient, held liable for costs, when Medicare does not cover the procedure (ex. when no Appropriate Indication, medical necessity/symptoms, is present)
(ACR classification for radiologic specimens)
1. All HR entries be dated and authenticated and authors identified
2. All written entries in INK
3. Use only medical staff approved abbreviations
4. Timely fashion
2) Delineate the scope of care
3) Identify Important Aspects
4) Identify Indicators
5) Establish a means
6) Collect & Organize Data
7) Initiate Evaluation
8) Take Actions to Improve
9) Assess Effectiveness
10) Communicate results
9. Respect and Caring
Federal legislation passed to improve the efficiency and effectiveness of the health care system; components that affect health information include privacy, security, and the establishment of standards and requirements for the electronic transmission of certain health information.
2. protect the PRIVACY of patient’s Health Information
3. protect the SECURITY of patient’s Health Information
4. help people OBTAIN/MAINTAIN Health Insurance benefits when they change jobs
More in general:
1) Protect patient information
2) Limit use of patient information
3) Penalize those who misuse information
Individual identifiable health information in any form or media. Information related to any healthcare provided to a person. It includes demographic information that can be used to identify the patient. That information can be used in some manner to identify the person.
Examples of PHI: 1) Lab reports; 2); X-Ray 3); Billing Systems; 4) Nursing notes; 5) Phone calls; 6) Conversations about patients.
(If you do not comply with policies concerning patient privacy:
It may cost you up to $250,000 or result in a 10 year jail sentence.
If you knowingly release patient information:
you may spend 1 year in jail, or pay a $50,000 fine.
If you gain access to health information under false pretenses:
5 year sentence or pay a $100,000 fine)
2. may be accused of criminal violations and can result in even larger penalties and fines and possible jail time.
3. may be excluded from participation in Medicare program.
4. may hurt reputation of hospital.
P.S.: A facility may not condition treatment on receipt of a valid authorization, except for participation in research studies.
– Patient is suspected victim of a crime;
– Upon court order;
– on Police request regarding criminal investigation;
– When caregiver suspects child abuse and reports it to police;
– FDA requires report about medical devices;
– Communicable diseases must be reported to state health agencies (who, w/ID, has been infected and what was contracted)
Short records of 15 pages = $ 2 – $55
Long records of 500 pages= $15 – $585
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