Chapter 25 Flashcards
Who maintains health records?
Hospitals
Ambulatory Care Facilities
Emergency & Trauma Centers
Nursing Homes
Rehab Facilities
Home care programs
Physcian Practices
What is the purpose of HIM and Technology?
Continuity and quality of care provided for the patient
What forms are used for HIM?
Hard copy
Microfilm
Computerized
The health records department functions to support:
Care of patients
Administrative process
Billing & Accounting
Medical Education programs
Research
Utilization Mngmt
Risk Mngmt
Quality Assurance programs
HIPAA
Legal requirements
Extraneous patient serivces
What can happen if there is an error in medicine?
Wrong exam
Allergic reaction
What can happen if there is a data reporting error?
Misdiagnosis
Loss of revenue
Who sets the standards for health records?
TCJ - The Joint Commission
HFAP - Healthcare facilities Accredidation program
Who is CMS and what is their purpose?
Center for Medicare and Medicaid Services
Oversee and authorize TJC and HFAP to survey medical facilities
What is charting?
Documenting patient care in health record
When do radiologists chart?
When patient received diagnostic procedure
When contrast is involved
Clinical data and patient history
What is the RIS?
Radiologic Information System (patient history, exam, etc)
What is HIS?
Hospital Information System (insurance, employment, etc)
What is EHR?
Electronic Health Record
Health record must include what for procedures requiring consent?
Informed consent form
Does consent for treatement upon admission to the hosptial cover consent for specific procedures?
No
What are incident reports?
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
What form is required to perform a procedure?
Order form or request form
What is ABN?
Advanced Beneficiary Notice - lets patient know that Medicare may not cover procedure and they are responsible for it. They sign it.
What type of report must be created for each radiologic procedure?
Patient report - radiologist must sign each report
Where are reports stored?
Film file (RIS) and in patient’s permanent record
All patient records must be:
Dated and authenticated
How to correct an error?
Single line through it
Write “error” and correct term
Date and sign it
What is the basic principle of patient record?
If it’s not documented, it’s not done
What is patient coding?
Coverting diagnosis and procedures into a numeric classification system
What is PPS?
Prospective Payment System
Who enacted the PPS? When?
Federal goverment in 1983
How are hopsitals paid under PPS?
Pre-determined rate for each Medicare admission according to the patient’s DRG
Who controls PPS?
CMS under HHS
What is DRG?
Diagnostically Related Group - patient’s will fall into a DRG based on their medical condition
What type of setting are DRGs used in?
Inpatient setting
What is APC?
Ambulatory Patient Classification - reimbursement in the outpatient setting
What is CPT?
Current Procedural Terminology
What is CPT used for?
Code outpatient procedures and ancillary services such as radiology and laboratory
What numerical coding method is used for DRG?
ICD-10-CM
What is ICD-10-CM?
International Classification of Diseases, 10th revision, Clinical Modiciation
What do we primarily use CPT codes for?
Procedures
What is IRD?
Index of Radiologic Diagnosis
What is IRD used for?
Specimens
How to correct/amend a health record mistake?
Must be fixed by the author of the mistake
Line out the error
Write “error”
Sign and date
Can the patient amend their health record?
Yes - can add additional amendments but can’t change original
What must be inlcuded to get health records released?
Consent in writing:
Who is receiving the info
Pt name, address, birthdate, extent of information, signature
What is MQSA?
Mammography Quality Standards Act - more stringent procedures for keeping images and for how long
Are original records left at the court?
No, copies are made
Copies can be sent through certified mail
What is HIPAA?
Health Insurance Portability and Accountability Act
Who and when enacted HIPAA?
Congress in 1996
When did HIPAA go into effect?
April 14, 2003
Who is the enforcment agency for HIPAA?
Department of Health and Human Services
Who writes and maintains HIPAA?
Office of Civil Rights
What organizations must comply with HIPAA?
Health care providers, health plans
What is PHI?
Protected Health Information - if information is not related to treatement, authorization is required
What is Accounting of Disclosure?
A record that indicates who received patients information, for what purpose and when released
What determines who may and may not be given information?
TPO - treatment, payment and operation needs (information may be given if it falls into these categories)
What is required on portable devices for PHI?
Security software
Encryption of data
Firewalls
What is Incidental Disclosure?
If you inadvertently over hear or see information about a patient that you don’t need to know
When a child turns 18, the parent turns into the:
Advisor
Ethic investigations of ARRT:
2010-7
2011-13
2012-25
2013-30
What is FERPA?
Family Educational Rights and Privacy Act
What does FERPA protect?
Protects privacy of Student Education Records
Rights to student transfer at 18
Rights include:
-can inspect and review
-can request school to correct
