Mr. Green Week 4 Exam

The clinic physician records ___________ information when QUESTIONING patients about their illness.
subjective

The clinic physician records ____________ information when EXAMINING the patient.
objective

Georgina avoids _________ by taking care of issues and documents as they are presented to her rather than setting them aside for later.
procrastination

Naomi has a __________ interest in the success of a new hospital, because she owns shares in its stock.
vested

The MA must never remove entries in a patient’s record by _________.
obliteration

Dr. Lupez’s __________ __________ was irritable bowel syndrome, not colon cancer.
provisional diagnosis

Jose read the memo about the new medical records _____________ schedule with interest, because his job includes filing.
retention

What are some reasons medical records are kept?
1.)continuity of care
2.) legal protection for those who provide care for the patient.
3.) Statistical info. that is helpful to researchers.
4.) financial reimbursement

Explain the concept of ownership of medical records.
The owner of the physical medical record is the PHYSICIAN or medical facility, often called the “maker” that initiated & DEVELOPED the record

What are two major types of patient records found in a medical office?
1.) paper medical records
2.) electronic medical records

List and explain the filing steps:

The electronic record that originates from ONE facility is called the electronic…
EMR record

The electronic record that originates from MORE THAN ONE facility is called the electronic…
EHR record

A system that is capable of interacting with another system is said to be …
interoperable

A(n) _________ -based medical record is used in combination with a paper-based record to optimize patient care.
computer

Medical _____________ refers to the study of medical computing.
informatics

Any of a set of physical properties, the values of which determine characteristics or behavior , is its____________.
parameters

Advantages of the EMR system:
1.) savings in time and money
2.) reduced staffing needs
3.) fewer medical errors
4.) faster retrieval of information
5.) enormous technologic capabilities

Disadvantages of the EMR system:
1.)patient concerns about confidentiality
2.) staff training
3.) staff acceptance
4.) space and storage issues

What is the approximate cost of implementing an EMR system for a typical physician’s office with one physician?

Janie records any ____________ that happens to a patient while he or she is in the hospital.
sentinel events

Betty reminded Joanne to be careful not to _________ numbers or letters when entering information into the computer.
transpose

The _________ __________ office in a healthcare facility is concerned with providing the best and most efficient care possible to the patients.
quality assurance

Dr. Hughes knew that penicillin was a(n) _______ for Kathleen Schultz, so he ordered a different antibiotic.
contra-indication

An injury caused by medical management rather than the underlying condition of the patient is called a(n) ____________ event.
adverse

A _______ ________ is a medical error that is corrected before it affects the patient.
near miss

Define health information management in lay terms.

List five ways in which healthcare info/data is used.
1.) helps ensure continuity of care from provider to provider.

2.) Assist manufacturer’s in determining side effects of drugs

3.) It provided statistical info about primary and secondary diagnoses

4.) It helps the medical facility plan for future needs and capital equipment

Explain what is meant by the UNDERUSE of medical services.
patients do not take advantage of many services they should be using, especially if they are at-risk patients.

Explain what is meant by the OVERUSE of medical terms.
(excessive use) Example: using the ER department for nonemergencies

Dr. Lawton is considered a healthcare ________, because he provides services and treatments to patients.
provider

The ______________ against Dr. Rosales was one of his former patients, Risa Jackson, who believed that his staff had violated her privacy.
complainant

Roberta was assigned to be the temporary __________ ___________ at the clinic while Maritza was on maternity leave.

Health information that is transmitted in electronic form is called ______________ _____________.

The patient’s information that pertains to his or her health is called ____________ ___________ ______________.

List the benefits provided by the HIPAA Privacy rule to patients and/or providers.
1.) Patients more control over their health records
2.) Patients are able to make informed choices on how their personal health info is used.
3.) Safeguards are established that health providers make sure to protect the privacy and health info.
4.) Violators are held accountable and face both civil and criminal penalties if a patient’s privacy rights are compromised.
5.) Protects public health by striking a balance when public responsibility supports disclosure of personal health info.

Briefly explain the Title I provision of HIPAA.
Covers the insurance industry. It limits the use of pre-existing health conditions that in the past would have prevented an employee from obtaining health insurance coverage or limited the coverage.

Briefly explain the Title II provision of HIPAA
administrative simplification. The goal is to reduce administrative costs in the healthcare industry.

List the rights of the patients of the privacy rule:
right to notice of a facility’s privacy practices

the right to have access to view, copy, and obtain a copy of their personal health info.

the right to restrict certain parts of uses of their PHI

the right to request that communications from the facility be kept confidential

the right to ask the facility to amend the PHI

The right to receive notice of all disclosures of their PHI

State several reasons accurate medical information is important.
1.) So that the correct care can be given to the patient.
2.) Helps to ensure continuity of care b/w providers so that no lapse in treatment occurs.
3.) The record serves as indication and proof in court that certain procedures and treatments were performed on the patient. (therefore it can be excellent legal support if it is well maintained and accurate)
4.) Aid researches in statistical info.

Differentiate between subjective and objective information.
subjective info is provided by the patient. (address,SSN,insurance info, and explanation of what he/ she is experiencing. “chief complaint.) objective info is provided by the physician or provider and obtained through the physician’s questions and observation made during the exam.

Describe various types of information kept in the medical record.
subjective and objective info in the progress notes, demographic inf, many types of reports,consultations, lab reports, radiology and other imaging reports, and various types of correspondence.

Explain how to make additions to a medical record.
items periodically must be added to patient’s records, such as when test results arrive or new information becomes available.

Discuss correction of an entry in the patient record.
A single line should be drawn through the incorrect information and then initialed and dated. Some offices may require a notation of “Corr.” or “Correction” on the chart. Correction should also be provided on the side of mistake if theirs room or above the mistake, if there’s not any room on the side.

Describe indexing rules:
1.) The papers are conditioned-preparatory stage for filing
2.) The documents are released- their are ready to be filed b/c they have been reviewed or read some type of mark has been placed on the document to indicate this.
3.) The documents are indexed, which involves deciding where each document should be filed coding it with some type of mark on the paper indicating that decision.
4.) Sorting involves placing the files on in filing sequence.
5.) The actual filing and sorting of the documents is the last step.

Know the order of the 12 indexing rules:

What was the presidential Executive order that led to the implementation of EMR systems across the nation?
in August 2006 George W. Bush issued an executive order that presented the goal of having electronic health records for most Americans by the year of 2014. The order included 5 requirements. (Interoperable systems)

Discuss the principles of using the EMR.
allow record sharing among various healthcare entities in a geographic area.

physician can access hospital records on his or her patients, even if he or she was not an attending physician.

lab reports can be viewed on smart phones or pda’s w/o having to be mailed or faxed to the office

What are the capabilities of an electronic medical record system?
specialty practice components, appointment scheduling features, prescription writers, medical billing systems, charge capture, eligibility verification, referral management, laboratory order integration, patient portals, and many other features that vary from system to system.

Give several reasons why patients are hesitant about in accepting electronic health records.
they are concerned about the privacy of their health info, patients worry about lack of control over who views their record, safety of their records,

What’s the role of MA’s in regard to the changing of technology in healthcare facilities and organizations:
Be open and willing to learn, be encouraging to other staff members while training on the system, share your knowledge with others and assist when possible, do not expect to master the system in a week, realize that systems have a learning curve and be patient with and receptive to the educational process. Keep technical support numbers handy and feel free to use them. Offer those who might be struggling. make sure you attitude is enthusiasm, interest, and curiosity.

Contrast the nine characteristics of quality health plan.
1.) Validity- means the info is accurate.
2.) Reliability- means that the info can be counted on to be accurate and that medical decisions can be based on it.
3.) Completeness- means that the info is available in its entirety.
4.) Recognizability- means the data can be understood by users.
5.) timeliness- means the information is the latest available to the provider about a patient or treatment.
6.) Relevance- the usefulness of the health data
7.) Accessibility- means the information is easily available to the provider
8.) Security-involves efforts to keep unauthorized people from accessing the data.
9.) Legibility- refers to the correctness of the info. and it’s authentication by the healthcare provider.

What are the four concerns of quality insurance?
Overuse, Misuse,Underuse, and variations in the use of healthcare services.

Misuse-reflects errors, such as laboratory errors are misdiagnoses.
Variations in services -means that in different parts of the country, individuals use services in different ways , which can influence the quality of care overall in the United States.

Discuss the importance of HIPAA
HIPAA grant patients their right to privacy.HIPAA gives patients a siginificant degree of control in determining who access their records. Patients must also specifically authorize the use of dissemination of the information in their medical records.

Explain the function of JCAHO
offers accreditation to facilities that want to excel in healthcare services

Discuss the important of healthcare standards in medical facilities.
without strong healthcare standards, quality can not exist. Provide optimum quality! Organizations that seek accreditation or focus their efforts on quality will not only meet standards but EXCEED them.

Explain how HIPAA Privacy Rule benefits the healthcare industry.
gave patients more control over their health records.

These are the elements that must be included in a Notice of Privacy Practices:
details on how PHI is used and disclosed by the facility

the duties of the provider to protect health info.

The patient’s rights regarding PHI

how complaints can be filed if patients believe their privacy has been violated

whom to contact at the facility for more info.

the effective date of the Notice of Privacy Practices