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Z MRI Clinical Prep > chapter 23 Health Records > Flashcards

chapter 23 Health Records Flashcards

1
Q

who maintains health records

A

hospitals, ambulatory care facilities, ER and trauma centers, long term facilities, rehab facilities, home care programs, physician practices

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2
Q

promotes effective communication among health care professionals
continuity and quality of care
ensure complete documentation

A

why health records and health info. management

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3
Q

hard copy
microfilm
computerized

A

forms

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4
Q 
care of patients
institutions admin process
patient billing and accounting
medical education programs
research
utilization management
risk management
quality assurance program
HIPPA
legal requirements
follow up care
A

function of health records department

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5
Q

wrong exam done

allergic reaction

A

error in medicine

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6
Q

misdiagnosis

loss of revenue

A

error in data reporting

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7
Q

standards of health records are set by who

A

TJC (the joint commission)

HFAP(healthcare facilities accreditation program)

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8
Q

who is CMS

A

center for medicare and medicaid services. they authorize TJC/HFAP to survey medical facilities

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9
Q

if patient care involved must document in record (also known as charting)

A

health record content

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10
Q

when patient receives diagnostic procedure, contrast, reactions, clinical date, patient history

A

radiology dept when to chart

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11
Q

radiology information system(history, exam)

hospital information system(insurance, employment)

A

RIS, HIS

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12
Q

electronic health records
TJC establishes standards
facilities can have their own program

A

EHR

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13
Q

patient ID
medical history
diagnostic orders
reports

A

included in EHR

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14
Q

informed consent
consent for treatment
incident report (state facts not opinions)
administration keeps incident reports for legal purpose but it is not included in patients records

A

health record content

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15
Q

an order or request form to perform procedure
clinical date, history
if medicare does not cover must tell patient(advances beneficiary)
patient report
authentication signature by radiologist
stored in film, file, RIS or PACS and in patients file

A

health records in radiology

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16
Q

dated
date of exam
date of radiologists signature
authenticated by signature of radiologist
in ink
line thru error, write error, date and sign
“not documented, not done”

A

requirements of entries

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17
Q

coding of patients
diagnosis and procedures converted to numeric classification
complete and accurate

A

reimbursement requirements

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18
Q

System for Medicare patients
Federal govt enacted 1983
Hospitals are paid a predetermined rate according to DRG
CMS under HHS controls it

A

PPS Prospective Payment System

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19
Q

Determines standard care rate for a group

A

DRG diagnostically related group

20
Q

Reimbursement in outpatient setting

A

APC ambulatory patient classification

21
Q

Numerical coding system to indicate patients DRG diagnostically related group
Revision October 2015

A

ICD 10 CM

22
Q

Codes used for outpatient radiology and labs

A

CPT current procedural terminology

23
Q

Must be accurate to receive payment or deny
Ranges from 70010 to 79999
Example is cervical spine with contrast 72142

A

Reimbursement coding

24
Q

Used for coding specimens

A

IRD index of radiologic diagnosis

25
Q

May be used in court
You may be called upon for testimony or deposition
Incorrect billing is fraud must follow regulations

A

Legal aspects of health records

26
Q 
Must be author of mistake 
Line out
Write error
Date, sign
Can be amended by patient but original still exists
EHR more difficult to fix
A

Health records correcting or amending

27
Q

sign statement as student or employer
Refer them to physician with results
Privileged communication in some states

A

Confidentiality of health records

28
Q

Must be in writing
Who is receiving info
Patient name, address, date of birth, date, signature, extent of info
May be charged for copies

A

Consent to release

29
Q

Used if time is a factor
Required for 3rd party payer
Include confidentiality notice

A

Sending health records as a fax

30
Q 
Policy against sharing passwords, access codes, key cards
Password 7 characters 
Change frequently 
Access only info you need
Lock out if improper code
Access to records is tracked
A

Health records information security

31
Q 
Have right to access 
Can be charged for copies 
Hospitals ask for patient authorization 
Hospitals can hold back release
Don't share images with patient
A

Patient access to health records

32
Q

Record kept for 5 years

10 years if no previous record

A

MQSA mammography quality standards act

33
Q

Enacted by congress in 1996
Protects inappropriate access
Department of health and human services enforces it
Can be charged civil or criminally if not followed
Health care providers and health plans must follow

A

HIPPA health insurance portability and accountability act

34
Q

Any information that can identify a patient. If info not related to treatment must get patient authorization

A

PHI protective health information

35
Q

Can we share PHI?

A

Yes when part of our job

36
Q

Record of who received patients info, for what purpose, when released

A

Accounting of disclosure

37
Q

Determines who may be given info and who may not

A

TPO treatment, payment, operational needs

38
Q

Must have security software
Encryption of data
Firewalls

A

PHI in portable devices

39
Q

Give name and room number only

A

If asked over phone about patient

40
Q

Disposing of patient info

A

Shred

41
Q

Form patient signs giving permission for their PHI to be released, who is receiving and what purpose

A

Authorization form

42
Q

If you inadvertently over hear or see info about patient that you don’t need to know is termed

A

Incidental disclosure

43
Q 
Access EHR not involved with patient
Stolen laptop/lost, unsecured PHI
Posting patient info on social media 
EOB explanation of benefits sent to wrong guarantor
Access own EMR
Take pics of injuries
Non work related access
A

Breaches of HIPPA

44
Q 
Can get access to insurance info 
Confidential info remains confidential 
Sign new HIPPA form
In charge of own medical record
Parent listed as having access 
Parent is advisor
A

At age 18

45
Q

Check that policies are followed
Check computers
Check encryption

A

Periodic audits

46
Q

Allows judgement call and experience to decide if info can be released if in patients best interest
Can use sign in and call out
Images not violation if anonymous

A

HIPPA allows

47
Q

Protects privacy of student education records
Rights to students
Transfer at age 18
Can inspect, review, have school correct

A

FERPA family educational rights and privacy act

Z MRI Clinical Prep (12 decks)

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