Ch 1 - Medical Records and History Flashcards
what does HIPAA stand for?
health insurance portability and accountability act
provider’s impression
diagnosis
medical record
a written record of the important information regarding a PT, including the care of that individual and the progress of his or her condition
also serves as a legal document
Consequence of incomplete medical records?
used as evidence in court to show that a PT did not receive the quality of care that meets generally accepted standards
examples of office administrative documents
patient registration record
notice of privacy practices acknowledgement form
correspondence
examples of medical office clinical documents
health history report physical examination report progress notes medication record consultation report home health care report
examples of laboratory reports
hematology clinical chemistry immunology urinalysis microbiology parasitology cytology histology
examples of diagnostic procedure reports
electrocardiogram holter monitor colonoscopy spirometry radiology diagnostic imaging
examples of therapeutic reports
physical therapy report
occupational therapy report
speech therapy report
definition of medical administrative documents
administrative documents contain information necessary for efficient management of the medical office
definition of medical office clinical documents
medical office clinical documents include a variety of records and reports that assist the provider in the care and treatment of the PT
examples of hospital documents
history and physical operative discharge summary pathology emergency department
examples of consent documents
consent to treatment
release of medical information
what is the HIPAA privacy rule?
provide PT with better control over the use and disclosure of their health information
all health care providers, health plans, and health care clearinghouses that use, store, or transmit health information must comply with this rule
What is Notice of Privacy Practices
NPP must explain to PT how their PHI will be used and protected by the medical office
medical office must make reasonable effort to provide a NPP to each PT and obtain a signed acknowledgement from the PT to prove they have received a NPP
what is considered PHI?
health information that contains patient identifiable information
eg. name, SSN, telephone
examples of when a PT’s written consent is not required for the use or disclosure of PHI
medical treatments: PT referral to a specialist, emergency care at hospital, tests on pt performed by the laboratory
payment: determination of eligibility for insurance benefits, review of services provided for medical necessity, utilization review activities
health care operations: quality assessment activities, contacting PT with information about care or tx, employee review activities, training of health care students
examples of business associates whom the medical office may disclose PHI with respects to HIPAA Privacy Rule
medical laboratories transcription services law firms accounting firms software and hardware consultants billing services
what is a health history report?
a collection of subjective data about the PT
diagnosis
scientific method of determining and identifying a PT’s condition
list the seven parts of the health history
identification data chief complaint present illness past history family history social history review of systems
what is a chief complaint?
identifies the PT’s reason for seeking care
the symptom that is causing the PT the most trouble
how to document the Chief Complaint?
open ended question limit to one or two symptoms concise and brief onset/duration of the symptom never use diagnostic terms
specific location of area, intensity, precipitating factors
what is a present illness?
an expansion of the chief complaint and includes a full description of he PT’s current illness from the time of its onset
the MA completes this section by asking questions to elicit detailed information
examples of past history?
major illnesses childhood diseases unusual infections accidents and injuries hospitalizations and operations previous medical tests immunizations allergies current medications
examples of familial diseases
diabetes mellitus
hypertension
heart disease
allergies
examples of social history
education occupation living environment diet personal history exercise
how to correct a mistake in documentation in PPR?
draw a single line through incorrect information
write the word ‘error’ above incorrect data
including date MA’s first initial and last name, and credentials
what are progress notes?
document the PT’s health status and the care and treatment being received by the PT in chronological order
how to document a procedure?
date and time
type of procedure
outcome
patient reaction
how to document administration of medication?
date and time name of medication lot number dosage route of administration injection site used significant observations PT reactions
how to document a specimen collection?
date/time type of specimen area of body specimen was obtained note if sent to outside laboratory date sent where it was sent
how to document in house laboratory tests?
date/time
name of test
test results
other examples that require documentation from the MA?
missed or canceled appointments
telephone calls from PT
medication refills
changes in medication or dosage by provider
definition of a symptom
any change in the body or its functioning that indicates the presence of disease
