Chapter 21- The Health Record Flashcards

Question

HITECH:

Answer 1

- A law that enforces HIPAA. - HIPAA on steroids x10" - Gives providers incentives. $$ -Find doctors and providers and fine them for the ones not using electronic.

Answer 2

Serves as a legal document Documents health information and provides support for treatment plan Enables continuity of care Supports reimbursement claims Provides legal protection to provider(s) Provides statistical information for research

Answer 3

Paper and electronic (EHR) Benefits of EHR: Practice management capabilities Scheduling Billing and claims Report generation for quality control, research Storage space Safety from accidental destruction Financial incentives from government for implementation Promotes communication and continuity of care

Answer 4

Health record itself (paper or electronic) Provider or healthcare facility Information in health record (Patient) Vested interest, right to confidentiality Best practices for security of paper records

Answer 5

Never remove them from the facility; lock storage area when facility is closed)

Answer 6

Personal demographics Name, date of birth, home address, contact information, healthcare insurance, etc. Past medical history (PH or PMH) Previous illnesses, injuries, usual childhood diseases (UCD), hospitalizations, surgeries; current health status Family history (FH) Health or age and cause of death of grandparents, parents, siblings; hereditary diseases Social and occupational history (SH, OH) Marital status, substance use, diet, occupation, etc.

Answer 7

Chief complaint (CC) and history of present illness (HPI) CC is the reason for the visit Usually documented in patient’s own words (with quotation marks) OLDCARTS Allergies Immunization and medication records Physical exam Range of systems (ROS) for new patients Baseline Provider’s findings

Answer 8

Onset: When did it begin? Location: Where is it? Duration: How long has it been going on? Characterization: How would you describe it? Alleviating and aggravating factors: What makes it better? What makes it worse? Radiation: Does it stay in one location or move? Temporal factor: Isi it better or worse at different times of the day? Severity: Using a scale of 0 to 10, with 0 being none and 10 being worse the worse, how does it rate?

Answer 9

Progress notes Signs, symptoms, feelings, concerns Clinical findings from PE and labs, diagnostics Provider’s impression and diagnosis Treatment plan Laboratory and diagnostic imaging results Consultation reports Hospital documents Discharge summary, operative report, ED report.

Answer 10

A sign is something that can be measured or observed by others; also called objective data. Examples include redness, swelling or edema, blood pressure, and pulse. A symptom is something that is only perceived by the patient; also called subjective data. Examples include pain, headache, dizziness, and nausea.)

Answer 11

(Answers will vary and may include, for labs, tests on blood, urine, sputum, tissues, or other substances from the body; for diagnostic imaging, x-rays, CT scans, nuclear medicine scans, MRI, ultrasound.)

Answer 12

A medical consult occurs when a patient is referred to another healthcare provider for examination and treatment.

Answer 13

Correspondence, release of information forms, disclosure authorization forms, Notice of Privacy Practices (NPP), consent for treatment and authorization form, other consent forms, images/copies of health insurance card and patient ID, advance directives, past health records

Answer 14

Observations and data categorized according to source Examples: Provider (progress notes) Laboratory Radiology Hospital Consultations Reverse chronologic order

Answer 15

Reverse chronologic order is when the most recent item is listed first and the oldest item is last. One reason it’s used is that the provider and staff members do not have to search to the bottom of the record to find a recent laboratory report or a test.)

Answer 16

Database -CC, HPI, PE, labs Problem list -Each numbered and titled Plan -Numbered and titled diagnosis and treatment plan correlating to each problem on the problem list Progress notes -Structured notes numbered to correspond to each problem

Answer 17

Subjective data (S) -Obtained from patient; includes CC, HPI, other histories, ROS, current meds, allergies, etc. Objective data (O) -Clinical evidence, including vital signs, measurements, PE findings, labs, diagnostics results Assessment (A) Diagnosis correlated with problem number Provisional, differential Plan (P) Provider’s suggested treatments

Answer 18

A differential diagnosis is the process of weighing the probability of one disease causing the patient's illness against the probability that other diseases are causative.)

Answer 19

A provisional diagnosis is a temporary diagnosis made before all test results have been received

Answer 20

-SOAPE Evaluation -SOAPIE Intervention and evaluation -SOAPER Education and response -CHEDDAR CC Exam Details of problem and complaints Drugs and dosages Assessment Return visit or referral

Answer 21

What to document: Patient visits No shows Telephone calls Correspondence Electronic communication

Answer 22

Email, patient portal communications

Answer 23

Guidelines: Check patient name first Document immediately after procedure Document in order steps were completed Be accurate, specific, and concise Use correct words and facility-approved abbreviations Use quotation marks when recording patient’s own words Use punctuation Don’t use first person Review Handle errors correctly

Answer 24

Concise means using as few words as possible to express the message.

Answer 25

Guidelines: New entry on next blank line, starting with date MM/DD/YYYY followed by time Write legibly in ink (black preferred) Patient name and medical record number on each page Sign per facility policy Correction: Follow facility policy Draw a single line through error Insert correct above, after, or in the margin Write error Date and sign or initial with title

Answer 26

False. Obliteration is never acceptable

Answer 27

-Radio buttons and drop-down menus Enable standardization of content -Free-text boxes Used to document unique circumstances -Unique user identification Allows for audit trail

Answer 28

An audit trail is a record of computer activity used to monitor users' actions within software, including additions, deletions, and viewing of electronic records

Answer 29

Dictation: To say something aloud for another person to write down Machine transcription unit, portable transcription unit, phone system Transcription: To make a written copy of dictated or handwritten material Provider reviews and initials transcript before placement in health record Voice recognition software: Converts dictation into readable text

Answer 30

Drawer files Horizontal shelf files -Also called open file with fixed shelves Rotary circular files Electronic lateral files -Also called vertical carousel files Mobile shelving system Card files

Answer 31

Available space, potential volume of records, lock system, fireproof)

Answer 32

Divider guides Out guides File folders File folder dividers Labels -Patient name, allergies, advanced directive

Answer 33

-Basic systems Alphabetic by name Numeric Subject -Direct or indirect Advantages and disadvantages

Answer 34

Indexing rules Updated by Association of Records Managers and Administrators (ARMA) Use units -Surname (first unit) -Given name (second unit) Specifics for patients Specifics for businesses

Answer 35

Consecutive numeric filing - Also called straight numeric system Terminal digit filing Middle digit filing

Answer 36

Subject filing -Paper records are arranged and filed based on content or subject matter Alphabetic, numeric, or alphanumeric Color coding -Specific color identifies letter or number Ticker file -Chronological reminder system for tasks

Answer 37

System using a combination of letters and numbers

Answer 38

Group by patient Inspect for provider sign-off Prepare Index and code Sort per facility procedures Verify placement per facility policy Refile -Remove out guide

Answer 39

Electronic health record (EHR)- Electronic record of health-related patient info Conforms to nationally recognized interoperability standards Can be created/managed/consulted by authorized clinicians and staff from more than one healthcare organization. Electronic medical record (EMR)- Electronic record of health-related patient info Can be created/managed/gathered/consulted by authorized clinicians and staff within a single organization.

Answer 40

The EHR, because it facilitates continuity of care

Answer 41

Electronic record of health-related patient info Conforms to nationally recognized interoperability standards Can be drawn from multiple sources Managed, shared, and controlled by individual.

Answer 42

Electronic access to EHR for patients that enables Communication with provider Online form completion Prescription refill requests Appointment scheduling Meets some Promoting Interoperability Programs requirements.

Answer 43

Formerly known as the Medicare and Medicaid EHR Incentive Program, the Promoting Interoperability Programs encourage providers to adopt, implement, upgrade, and demonstrate meaningful use of certified electronic health record technology.

Answer 44

Answers may vary and may include as a service of healthcare insurance companies, employers, or healthcare facilities.

Answer 45

Encouraged widespread of adoption of EHR to -Improve efficiency and coordination of care -Improve privacy and security Through: Financial incentives linked to meaningful use E.g., e-prescribing, sharing health information to improve quality of care, submitting reports, using computerized physician/provider order entry (CPOE) Increased penalties for HIPAA violations

Answer 46

The ability to work with other systems.

Answer 47

Meeting the standards and regulations of the practice's established policies and procedures. Can also mean cooperation

Answer 48

EHR: Immunization data sharing with state registry Mobile access for providers Clinical decision support systems E-prescribing Appointment scheduling Lab order integration

Answer 49

PMS: Appointment scheduling New patient registration Insurance verification Billing, coding, financial management Claim denial management Electronic claim submission Financial and management reporting EHR and PMS: May have overlapping capabilities Interface

Answer 50

-Enter patient visit data Vital signs, measurements, allergies, medications, chief complaint, histories Update medications and vaccinations Review patient information for relevant needs Document procedures performed Document patient coaching -Arrange referrals -Schedule follow-up visits and/or tests -Scan and upload paper documents -Check patient portal for communications and requests

Answer 51

National standards that define and limit how PHI can be used or disclosed Also outlines patients’ rights regarding their PHI Examine their own health information Obtain a copy of their health records Request corrections be made if information is incorrect Permissions Reasons that health information can be released Disclosure authorization Records release process

Answer 52

National standards that define protections for electronic PHI (ePHI) Administrative safeguards Physical safeguards Technical safeguard Applies to records created, used, received, and maintained by covered entities

Answer 53

Backing up Process in which network files are copied using an external hard drive, server, online system, or cloud backup services HIPAA requires daily offsite EHR software backup Use of paper records in case of malfunction Plan to integrate data from paper into EHR

Answer 54

Record status: Active Inactive Closed Purging: Separating inactive from active records Retention schedule: Schedule outlining how long inactive and/or closed records are kept Destruction: Must be in accordance with federal and state laws Permanent log of destroyed records

Answer 55

7 to 10 years after patient’s last interaction with facility

Answer 56

Storage of paper records: Limited access, secure, temperature and humidity ranges, lockable area away from water and heat Retention of paper records: Sticker system Offsite storage Destruction of paper records: Burning or shredding

Answer 57

Storage of electronic health records Via backup Retention of electronic records Automated movement of inactive and closed records to different server May be placed on CDs, hard drives, inactive cloud space

Answer 58

Make eye contact when asking questions Look at the screen only when entering information Don’t shield the screen from the patient Sit next to or at an angle to the patient

Answer 59

Subjective

Answer 60

Last name, first initial, middle name

Answer 61

is a form of documentation that organizes patient data in a logical sequence.

Answer 62

- Dictate progress notes - Dictate letters - Generate emails

Answer 63

A paper record of a pt seen last year for a complete physical exam.

Answer 64

- has been seen within the past 1 to 5 years and need to be readily available for daily use.

Answer 65

are records of pt who have died, moved away, or otherwise terminated their relationship with the provider.

Answer 66

A dismissal letter will be sent to the pt and the pt is then considered dismissed by the clinic.

Answer 67

Alphabetic

Answer 68

CC {Chief Complaint}