question

Advance Directive

answer

a legal document that specifies an individual's healthcare wishes in the event that he or she has a temporary or permanent loss of competence

question

Consent

answer

a patient's acknowledgement that he or she understands a proposed intervention, including the intervention's risk, benefits, and alternatives; A patients agreement that health care information can be disclosed, the document provides a record of consent

question

(DNR) Do Not Resuscitate order

answer

A specific type of advanced directive in which an individual states that healthcare providers should not perform CPR if the individual experiences cardiac arrest or cessation of breathing

question

(DPOA) Durable Power of Attorney

answer

a power of attorney that remains in effect even after the principal is incapacitated; can be drafted to take effect only when the principal becomes incapacitated

question

(DPOA-HCD) Durable Power of Attorney for healthcare decisions

answer

a legal instrument through which a principal appoints an agent to make healthcare decisions on the principal's behalf in the event the principal becomes incapacitated

question

Express consent

answer

consent that is communicated through words, regardless of whether those words are spoken or written

question

General Consent

answer

a form that covers routine diagnostic procedures and medical treatment by hospital staff, as well as other activities such as release of information for treatments purposes and disposal of human tissue and body fluids consent

question

(GINA) Genetic Information Nondiscrimination Act

answer

Federal legislation that prohibits discrimination by health insurers and employers based on genetic information

question

Good Samaritan statute

answer

state law or statute that protects healthcare provides from liability for not obtaining informed consent before rendering care to adults or minors at the scene of an emergency or accident

question

(HIPPA) Health Insurance Portability and Accountability Act

answer

a law enacted by Congress on 8/21/96, governing various aspects f health information; federal legislation enacted to provide continuity of health coverage, control fraud and abuse in HC, reduce HC costs, and guarantee the security and privacy of health information

question

Implied consent

answer

consent for medical tx that is communicated through a person's conduct or some other means besides words

question

Informed consent

answer

a type of consent in which the patient should have a basic understanding of which medical procedures or tests may be performed as well as the risks, benefits, and alternatives for those tests or procedures

question

(IRB) Institutional review board

answer

a committee of at least five members with varying backgrounds that determines the acceptability of proposed human subjects research in accordance with institutional policies, applicable law, and standards of professional practice and conduct

question

Living Will

answer

a document executed by a competent adult that expresses the individual wishes to limit tx measures when specific health related dx or conditions exist

question

Long Form

answer

in the context of human subjects research, a consent form that includes all of the informed consent requirements included in the Common Rule

question

Non compos mentis

answer

Not of sound mind

question

(PSDA) Patient Self Determination Act

answer

a law that became effective in 1991 requiring HC institutions that bill MCR and MCD for services to provide adult patients with information about the various types of advance directives

question

(POA) Power of Attorney

answer

a legal instrument used by a principal(person) to grant legal authority to one or more agents to make certain legal and financial decisions on behalf of the principal

question

Short Form

answer

Is a written document stating the elements of informed consent required by the common rule have been orally presented to and understood by the subject(s) or the subject's legally authorized representative

question

Therapeutic privilege

answer

A doctrine that has historically allowed physicians to withhold information from patients in limited circumstances

question

(UAGA) Uniform Anatomical Gift Act

answer

An act that provides suggested standards for all aspects of organ donation, including who make anatomical gifts and hoe intent to make anatomical gifts should be expressed-designed to create uniformity in this area across all 50 states

question

(UHCDA) Uniform Health-Care Decisions Act

answer

a model law created in 1993 that provides that an individual may give an oral or written instructions to a HC provider that remains in force even after the individual loses capacity, and suggest decision-making priority for that individual's surrogates

question

hybrid health record

answer

a health record that uses a combination of paper and electronic format

question

Electronic health record

answer

a computerized record of health information and associated processes; an electronic record of health-related information on an individual that conforms to nationally recognized standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization

question

medicare

answer

- a program that provides healthcare services to qualified individuals

question

meaningful use

answer

- a requirement per the American Recovery and Reinvestment Act for healthcare providers to receive Medicare and Medicaid incentive payments; emphasizes collection of electronic data in the electronic health record (EHR) and subsequent use of EHR functionalities for tracking, reporting, and patient-care purposes

question

business record

answer

a record that is made and kept in the usual course of business; at or near the time of the event recorded

question

legal health record

answer

the form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organization's legal health record varies depending on how the organization defines it

question

designated record set

answer

- a group of records maintained by or for a covered entity encompassing medical records and billing record about individuals and enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan used, in whole or in part, by or for the covered entity to make decisions about individuals

question

custodian/ custodian of health record

answer

- the person designated as responsible for the operational functions of the development and maintenance of the health record and who may certify through affidavit or testimony the normal business practices used to create and maintain the record

question

Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) -

answer

federal statue, with state versions, that make admissible as evidence the reproduction of any record that has been retained in regular course of business and kept by a process that accurately reproduces the original in any medium; supports the transition from paper to electronic storage of information

question

joint commission

answer

an agency that develops standards for healthcare organizations and certifies healthcare organizations on the basis of adherence to those standards

question

Conditions of Participation (CoP)

answer

the standards that govern providers receiving Medicare and Medicaid reimbursements

question

Physician order

answer

a type of document within the health record that provides mandatory instructions regarding medical interventions such as treatments, ancillary medical services, tests and procedures, medications, or seclusion and restraint

question

Liability

answer

a legal obligation or responsibility that may have financial repercussions if not fulfilled; an amount owed by an individual or organization to another individual or organization

question

Authenticity

answer

the genuineness of a record that it is what it purports to be; information is authentic if proved to be immune from tampering and corruption

question

authentication

answer

verification of a record's validity and, therefore, it reliability and truthfulness as evidence; also a security mechanism to validate the identity of a user in an electronic system

question

handwritten signatures

answer

completed in ink, the most common method of authenticating paper health record

question

Rubber signature stamps

answer

a type of authentication for paper records; stamps must be used only by the person identified by the stamp in accordance with laws, standards, and regulations

question

initials

answer

an authentication method for paper health records that may be permitted in lieu of a full signature as long as the initials are readily identifiable as the author's through a signature legend on the same document

question

metadata

answer

data about data, information about an electronic data element's content

question

electronic signatures

answer

technological corollary to the handwritten signature in the paper record

question

digital signature

answer

a subset of e-signature technology

question

Computer key

answer

a number unique to a specific individual for purposes of authentication

question

Countersignature

answer

authentication by a second provider that signifies review and evaluation of the actions and documentation, including authentication, of a first provider

question

Auto-authentication

answer

a process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specified time period results in authentication

question

Accuracy

answer

the extent to which the information reflects the true, correct, and exact description of the care that was delivered with respect to both content and timing

question

Authorship

answer

the origination or creation of recorded information attributed to a specific individual or entity acting at a particular time

question

Abbreviations

answer

shortened form of a word or phrase

question

Legibility

answer

an aspect of the quality of provider entries; if an entry cannot be read, it must be assumed that it cannot be used or was not used in the patient care process

question

Amendment (addendum)

answer

a type of late entry in which information is added to support or clarify a previous entry

question

Late entry

answer

entry documented in health record when a pertinent entry was missed or was not written in a timely manner

question

Version management

answer

refers to how an organization handles the numerous versions that may exist of a document or collection of data

question

Timeliness

answer

the completion of a health record within timelines established by legal and accreditation standards and by organizational policy and medical staff bylaws

question

Completeness

answer

an element of a legally defensible health record; the health record is not complete until all its parts are assembled and the appropriate documents are authenticated according to medical staff bylaws

question

Personal health records

answer

an electronic or paper health record maintained and updated by an individual for himself or herself

question

Retention

answer

storage and retrieval of health records

question

Disposition

answer

destruction transfer or loss of health records

question

Master patient index (MPI)

answer

a patient identifying directory

question

Retention schedule

answer

a timeline for records retention based on factors such as federal and state laws, statues of limitations, age of patient, competency of patient, accreditation standards, AHIMA recommendations and operational needs

question

Destruction of records

answer

the act of breaking down the components of a health record into pieces that can no longer be recognized as parts of the original record; for example, paper records can be destroyed by shredding, and electronic record can be destroyed by magnetic degaussing

question

Transfer of health records

answer

moving of a record from one medium to another or to another records custodian

question

Uniform Electronic Transactions Act

answer

federal statute that makes electronic transactions as enforceable as paper transactions, removing barriers to electronic commerce and increasing trust associated with electronic business transactions

question

Electronic Signature in Global National Commerce Act

answer

an act passed in 2000 that gives e-signatures the same legality as handwritten signatures where interstate commerce is involved and that provides guidance on how records may be stored and retained electronically

Chapter Informatics And Information Management – – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards