Chapter 8- Health Information Management

Question 1

PHI

Answer 1

Protected Health Information

Question 2

Covered entity

Answer 2

Health insurance plans, health care clearinghouses, and health care providers who use electronic billing, funds transfers and electronic health records.

Question 3

Clearinghouses

Answer 3

entities that receive, review, send, and manage insurance claims for physicians

Question 4

EHR

Answer 4

Electronic Health Record

Question 5

4 parts to HIPAA’s administrative simplification

Answer 5

• Electronic transactions
• Privacy requirements
• Security requirements
• National identifier requirements

Question 6

What is the recommended fee for reproducing medical records?

Answer 6

No more than $1/page, or $100 for entire record

Question 7

Things to remember regarding releasing medical records

Answer 7

• Must be authorized by patient or legal guardian
• Request for records must be in writing with original signature
• Never release information contained in a medial record via telephone

Question 8

6 important factors of how medical records shoudl be kept

Answer 8

• Easily retrievable
• Kept in an orderly manner
• Complete
• Legible
• Accurate
• Brief

Question 9

Flow sheet

Answer 9

Designed to limit the need for long handwritten care notes; info is recorded in graphic or table form

Question 10

Progress notes

Answer 10

Statements about various aspects of patient care; reflects each encounter with patient chronologicallyp

Question 11

What should be done with reports before they are added to the medical record?

Answer 11

Should be read and initialed by the physician before they are added to the chart

Question 12

4 steps to ensure efficient and speedy filing and document retrieval

Answer 12

• Condition; no paper clips or tape, PT name on all sheets of paper
• Index; separate business records from PT records
• Sort; put in order that they will be filed in
• Store; place in storage area

Question 13

3 classes of medical records

Answer 13

Active, inactive or closed

Question 14

Inactive records

Answer 14

• PT has not been in office in 2-3 years

- still kept in office

Question 15

Closed records

Answer 15

-Have terminated their relationship with physician due to moving, termination by physician, or death

Question 16

When is statute of limitations up for minors?

Answer 16

Until child reaches legal age in every state

Question 17

SOAP

Answer 17

Subjective
Objective
Assessment
Plan

Question 18

POMR

Answer 18

Problem
Oriented
Medical
Record

Question 19

HIPAA officer

Answer 19

Coordinates and oversees the various aspects of compliance

Question 20

Workers comp cases should be kept open for how long after last date of treatment?

Answer 20

2 yrs.

Question 21

Master patient index

Answer 21

A cross reference in numeric filing

Question 22

5 Responsibilities of HIPAA officer

Answer 22

• assess, establish, and review policies and procedures
• coordinate mandatory training
• monitor access to health info by checking for security threats
• ensure sound practices, e.g passwords and access to certain info
• making sure data is not altered or destroyed

Question 23

Patient authorization

Answer 23

• release only info relating to specific disorder
• specify time limit
• drug, alcohol, and std info must be specifically listed to release info

Question 24

All physicians with Medicare/Medicaid patients must be using EHR by the year…..?

Answer 24

2017

Question 25

Medical assistants role

Answer 25

2 main things are data collection and patient care

Must guard electronic and paper records as the same.

Question 26

Medical history forms

Answer 26

Commonly used to gather info before the visit with the physician

Question 27

Why is it important for medical records to be legible and neat?

Answer 27

It can help with or prevent a lawsuit