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Intro to Radiography > Chapter 25 > Flashcards

Chapter 25 Flashcards

1
Q

Who maintains health records?

A

Hospitals
Ambulatory Care Facilities
Emergency & Trauma Centers
Nursing Homes
Rehab Facilities
Home care programs
Physcian Practices

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2
Q

What is the purpose of HIM and Technology?

A

Continuity and quality of care provided for the patient

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3
Q

What forms are used for HIM?

A

Hard copy
Microfilm
Computerized

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4
Q

The health records department functions to support:

A

Care of patients
Administrative process
Billing & Accounting
Medical Education programs
Research
Utilization Mngmt
Risk Mngmt
Quality Assurance programs
HIPAA
Legal requirements
Extraneous patient serivces

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5
Q

What can happen if there is an error in medicine?

A

Wrong exam
Allergic reaction

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6
Q

What can happen if there is a data reporting error?

A

Misdiagnosis
Loss of revenue

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7
Q

Who sets the standards for health records?

A

TCJ - The Joint Commission
HFAP - Healthcare facilities Accredidation program

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8
Q

Who is CMS and what is their purpose?

A

Center for Medicare and Medicaid Services

Oversee and authorize TJC and HFAP to survey medical facilities

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9
Q

What is charting?

A

Documenting patient care in health record

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10
Q

When do radiologists chart?

A

When patient received diagnostic procedure

When contrast is involved

Clinical data and patient history

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11
Q

What is the RIS?

A

Radiologic Information System (patient history, exam, etc)

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12
Q

What is HIS?

A

Hospital Information System (insurance, employment, etc)

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13
Q

What is EHR?

A

Electronic Health Record

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14
Q

Health record must include what for procedures requiring consent?

A

Informed consent form

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15
Q

Does consent for treatement upon admission to the hosptial cover consent for specific procedures?

A

No

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16
Q

What are incident reports?

A

Administrative document completed after an incident - legal or RM

Known facts only

Report is not part of the patient’s record, but event is still documented in chart

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17
Q

What form is required to perform a procedure?

A

Order form or request form

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18
Q

What is ABN?

A

Advanced Beneficiary Notice - lets patient know that Medicare may not cover procedure and they are responsible for it. They sign it.

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19
Q

What type of report must be created for each radiologic procedure?

A

Patient report - radiologist must sign each report

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20
Q

Where are reports stored?

A

Film file (RIS) and in patient’s permanent record

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21
Q

All patient records must be:

A

Dated and authenticated

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22
Q

How to correct an error?

A

Single line through it
Write “error” and correct term
Date and sign it

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23
Q

What is the basic principle of patient record?

A

If it’s not documented, it’s not done

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24
Q

What is patient coding?

A

Coverting diagnosis and procedures into a numeric classification system

25
Q

What is PPS?

A

Prospective Payment System

26
Q

Who enacted the PPS? When?

A

Federal goverment in 1983

27
Q

How are hopsitals paid under PPS?

A

Pre-determined rate for each Medicare admission according to the patient’s DRG

28
Q

Who controls PPS?

A

CMS under HHS

29
Q

What is DRG?

A

Diagnostically Related Group - patient’s will fall into a DRG based on their medical condition

30
Q

What type of setting are DRGs used in?

A

Inpatient setting

31
Q

What is APC?

A

Ambulatory Patient Classification - reimbursement in the outpatient setting

32
Q

What is CPT?

A

Current Procedural Terminology

33
Q

What is CPT used for?

A

Code outpatient procedures and ancillary services such as radiology and laboratory

34
Q

What numerical coding method is used for DRG?

A

ICD-10-CM

35
Q

What is ICD-10-CM?

A

International Classification of Diseases, 10th revision, Clinical Modiciation

36
Q

What do we primarily use CPT codes for?

A

Procedures

37
Q

What is IRD?

A

Index of Radiologic Diagnosis

38
Q

What is IRD used for?

A

Specimens

39
Q

How to correct/amend a health record mistake?

A

Must be fixed by the author of the mistake

Line out the error

Write “error”

Sign and date

40
Q

Can the patient amend their health record?

A

Yes - can add additional amendments but can’t change original

41
Q

What must be inlcuded to get health records released?

A

Consent in writing:
Who is receiving the info
Pt name, address, birthdate, extent of information, signature

42
Q

What is MQSA?

A

Mammography Quality Standards Act - more stringent procedures for keeping images and for how long

43
Q

Are original records left at the court?

A

No, copies are made
Copies can be sent through certified mail

44
Q

What is HIPAA?

A

Health Insurance Portability and Accountability Act

45
Q

Who and when enacted HIPAA?

A

Congress in 1996

46
Q

When did HIPAA go into effect?

A

April 14, 2003

47
Q

Who is the enforcment agency for HIPAA?

A

Department of Health and Human Services

48
Q

Who writes and maintains HIPAA?

A

Office of Civil Rights

49
Q

What organizations must comply with HIPAA?

A

Health care providers, health plans

50
Q

What is PHI?

A

Protected Health Information - if information is not related to treatement, authorization is required

51
Q

What is Accounting of Disclosure?

A

A record that indicates who received patients information, for what purpose and when released

52
Q

What determines who may and may not be given information?

A

TPO - treatment, payment and operation needs (information may be given if it falls into these categories)

53
Q

What is required on portable devices for PHI?

A

Security software
Encryption of data
Firewalls

54
Q

What is Incidental Disclosure?

A

If you inadvertently over hear or see information about a patient that you don’t need to know

55
Q

When a child turns 18, the parent turns into the:

A

Advisor

56
Q

Ethic investigations of ARRT:

A

2010-7
2011-13
2012-25
2013-30

57
Q

What is FERPA?

A

Family Educational Rights and Privacy Act

58
Q

What does FERPA protect?

A

Protects privacy of Student Education Records

Rights to student transfer at 18

Rights include:
-can inspect and review
-can request school to correct

Intro to Radiography (15 decks)

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