chapter 4

Question 1

Subpoena duces Tecum

Answer 1

“bring with you under penalty of punishment” a requirement that documents be delivered to a court or brought with you to court

Question 2

insurance

Answer 2

the transfer of an obligation from one party to another, usually in exchange for a fee

Question 3

actuarial tables

Answer 3

a comprehensive list of statistical data

Question 4

upcoding

Answer 4

using an incorrect international classification of diseases (ICD) or current procedure terminology (CPT) code to gain a larger insurance payment

Question 5

respondeat superior

Answer 5

“let the master answer” the employer is responsible for its employees

Question 6

vicarious liability

Answer 6

liability w/o fault. being held accountable for ones action even though you committed no wrong

Question 7

contract

Answer 7

an agreement between parties that the law will recognize

Question 8

reasonable person standard

Answer 8

a legal standard used to determine whether the actions of a party are warranted

Question 9

medical records used to

Answer 9

manage healthcare
track healthcare
provide clinical data
meet regulatory requirements
document healthcare

Question 10

managing healthcare

Answer 10

reviewing patients medical history

• past diseases
• past treatments
• past response to care

Question 11

tracking care

Answer 11

why a patient sought medical care
where a patient received care
what medical care was provided
when the patient received care
hoe the patient responded to care

Question 12

providing clinical data

Answer 12

research
statistical information
public health officials

Question 13

regulatory requirements

Answer 13

Joint Commision in Accreditation of Healthcare Organizations (JCAHO)

• Evaluates records
• determines compliance with standards
• required for Medicare/Medicaid

Question 14

documenting

Answer 14

what to write

• medical approach
• legal approach

Question 15

medical approach

Answer 15

pertinent information
who, what, where, when, and how
review the purposes of medical records serve

Question 16

legal approach

Answer 16

legal document
possible use in lawsuits and trial
used to demonstrate what care was provided
used to refresh your memory
what is NOT written
subpoena ducus tecum

Question 17

medical record ownership

Answer 17

dually owned by both the patient and the healthcare institution

• institution: paper
• patients: information
• Doctrine of professional discretion: allows a physician to decide whether to release a patients medical records or not
  
  • hypochondriacs: a patients who have a preoccupation with disease and illness
  • psychological/psychiatric records: with holding information for the safety of the patient

Question 18

storage and retention

Answer 18

statue of limitations
legal maxim
20 years from last date of service

Question 19

insurance

Answer 19

written for anything
car insurance example
actuarial tables
premiums

Question 20

managed care

Answer 20

skyrocketing healthcare costs
economize healthcare spending
ICD codes: inpatient
CPT codes: outpatient
upcoding

Question 21

legal document

Answer 21

any writing that provides information or ideasthat can be attributed to the author

Question 22

malpractice insurance

Answer 22

all healthcare providers
employment provided malpractice insurance
respondeat superior
vicarious liability

Question 23

elements required for contracts

Answer 23

offer: though of as a desire to enter an agreement
acceptance: the taking of the offer, does not require a verbal response
consideration: whether the parties have thought about what they are giving up when entering into a contract
- contractual capacity
- implied contracts
- reasonable person standard

Question 24

statue of fraud

Answer 24

a law that indicates when a contract must be in writing in order for the courts to recognize that contract

• executors/administrator agreements
• Employement contracts
• interest in land
• the sale of any item $7,500 or more