TMA: Chapter 38 – Flashcards
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What is the meaning of the acronym HIPAA?
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Health Insurance Portability and Accountability Act
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Source-oriented record
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often used for organizing paper based patient record
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Electronic health record
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maintaining patient health info on computer.
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Problem-oriented record
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organized according to the patients health problems
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Who must comply with HIPAA?
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All health care providers, health plans and health care clearing houses (billing services) that use, store, maintain or transmit health info
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What is the purpose of the HIPAA privacy rule?
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Provide patients with better control over the use and disclosure of their health info
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When is a consent to treatment form required?
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All surgical operations and nonroutine therapeutic and diagnostic procedures (ex. sigmoidoscopy) performed in the medical office.
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What information must the patient receive before signing a consent to treatment form?
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The nature of patients condition, nature and purpose of procedure of recommended procedure, explanation of risks involved with procedure, alternative treatments or procedure available, likely prognosis, risks of declining or delaying procedure
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What is the purpose of progress notes?
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Serve to document patients health status from one visit to the next.
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List 3 categories of medication that may be included in a medication record
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prescription, OTC, herbal and natural remedy products, immunization, and meds administered at the medical office
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List 3 uses of the health history
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1. Determine patients general state of health 2. Arrive at a diagnosis and to prescribe treatment 3. Document any change in a patients illness after treatment has been instituted.
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What does witnessing a signature mean?
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The MA verified the patients identity and watched the patient sign the for,.
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What are the tow common types of medical record.
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Paper based medical record & Electronic Medical Record
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What is the difference between physical therapy and occupational therapy?
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Physical Therapy: Use of therapeutic exercise and other physical agents to restore function and promote healing after an illness or injury. *Occupational therapy: helps a patient learn new skills to adapt to a physically, developmentally, emotionally or mentally disabling conditions
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What are the 7 parts of the health history?
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1. Identification Data 2. Chief Complaint 3. Present illness 4. Past history 5. Family history 6. Social history 7. Review of systems
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What is a chief complaint?
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Identifies the patients reason for seeking care- that is the symptom that is causing the patient the most trouble
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When must a patient complete a release of medical info form?
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If a patient is moving to another state and wants to transfer their medical records to a new physician
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What guidelines should be followed in recording the chief complaint?
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Open-ended questions. CC should be limited to 1 or 2 symptoms. CC should be recorded concisely and briefly. Duration of symptoms. MA should avoid using names of disease or diagnostic terms
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List 3 example of subjective symptoms
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1. pain 2. nausea 3. vertigo
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What is the purpose of an operative report?
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Describes the surgical procedure and must be completed and signed by the surgeon who performed the operation
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List 3 example of objective symptoms
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1. coughing 2. rash 3. cyanosis
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What medical information is protected by law and cannot be released unless specifically authorized by the patient?
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Mental health diagnosis/treatment Sexually transmitted disease
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Explain the importance of social history
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The patients lifestyle may have an impact on their condition and may influence the course of treatment chosen by the physician
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What is the purpose of the review of systems (ROS)?
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A systematic review of each body system to detect any symptom that have not yet been revealed
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What is the purpose of the physical exam?
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Provide objective data about the patient, which assists the physician in determining the patients state of health
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What is a Notice of Privacy Practices (NPP)?
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Explains to patients how their protected health info (PHI) will be used and protected by the medical office
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List examples of when HIPAA does not require written consent for the use or disclosure of a patient's health info in the following categories: Treatment
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Patient referral to specialist, emergency care at hospital
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List examples of when HIPAA does not require written consent for the use or disclosure of a patient's health info in the following categories: Payment
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Determination of eligibility for insurance benefits
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List examples of when HIPAA does not require written consent for the use or disclosure of a patient's health info in the following categories: Health care operations
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Quality assessment activities
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What 2 general categories of info are including on a patient registration record?
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1. Demographic info 2. Billing info
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What is the purpose of home health care?
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To minimize the effect of disease or disability by promoting, maintaining and restoring the patients health
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List 5 examples of home health services
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1. Cardiac home care 2. IV therapy 3. Respiratory therapy 4. Pain management 5. Diabetes management
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What is the purpose of a laboratory report?
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Relay the results of lab tests to the physician to assist in diagnosing and treating disease
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List 5 examples of diagnostic procedure reports
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1.ECG Report 2. Holter Moniter Report 3. Sigmoidoscopy report 4. Colonoscopy report 5. Radiology report
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What is the purpose of a therapeutic service report?
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It documents the assessments and treatments designed to restore a patients ability to function
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List examples of physical agents used in physical therapy?
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Therapeutic exercise, thermal modalities, cold and hydrotherapy, electrical stimulation and massage
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What is speech therapy?
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Treatment for the correction of a speech impairment resulting from birth, disease, injury or previous medical treatment.
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What is the purpose of the discharge summary report?
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Document info needed by patient's physician to provide for the continuity of future care
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What is included in a pathology report?
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A macroscopic and a microscopic description of tissue remoced from a patient furing surgery or a diagnostic procedure
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Why is a copy of the emergency room report sent to the patient's family physician?
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For the purpose of providing follow-up care
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What is the purpose of a consent to treatment form?
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Required to perform certain procedures or to release info contained in the patients medical record
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When does a release of medical info form not have to be completed?
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Disclosure of protected health info (PHI) for purpose of medical treatment payment and health care operations (TPO)
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What is the difference between a PPR and an EMR
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PPR - paper based patient records EMR- is electronic medical record
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What functions are performed by an EMR software program?
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Allows for creation, storage, organization, editing and retrieval of medical records
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How are documents organized in a source-oriented medical record?
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Organized into sections based on department, facility or other source that generated the info (eg: lab, hospital, consultant)
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What is reverse chronological order?
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The most recent document is placed on top or in front of the others. The oldest is at the bottom
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How are documents organized in a problem-oriented medical record (POR)
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Organized according to the patient's health problems
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List and describe the 4 parts of a POR
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1. Establishing a database 2. Compiling a problem list 3. Devising a plan of action for each problem 4. Following each problem with progress notes
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List and describe the format used to organize progress notes in a POR
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SOAP 1. Subjective data 2. Objective data 3. Assessment 4. Plan
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How can a health history be entered into the EMR?
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The patient can complete paper to pencil form and the MA can enter ir into computer or the MA can ask patient info and enter it automatically
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What is the current illness and how is this information obtained?
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Present Illness (PI) is an expansion of the CC and includes a full description of thee patients current illness from time of its onset
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List 5 examples of info included in the past medical history
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1. major illness 2. childhood diseases 3. accidents/injuries 4.immunizations 5.allergies
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List 3 examples of familial diseases
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1. hypertension 2. heart disease 3.allergies
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List the guidelines that should be followed to ensure accurate and concise charting
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1. check the name on chart first 2. use black ink 3. write legibly 4. chart info accurately using clear phrases
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What is the difference between productive and non productive cough?
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When phlegm comes out with the cough it is a productive cough.
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Why should the following be charted in a patients medical record: *procedures performed on the patient
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From a legal standpoint a procedure not documented was not performed
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Why should the following be charted in a patients medical record: *Specimens collected from a patient
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The physician would know that the specimen was collected and sent out to the lab if results were not back yet
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Why should the following be charted in a patients medical record: *laboratory tests ordered for the patient
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Protects the physician legally, refreshes the physicians memory when they are not back yet
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Why should the following be charted in a patients medical record: *Instructions given to the patient regarding medical care
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Protects the physician legally in case in the event a patient doesn't follow the instructions and causes further harm or damage
