Chapter 8- Health Information Management Flashcards
PHI
Protected Health Information
Covered entity
Health insurance plans, health care clearinghouses, and health care providers who use electronic billing, funds transfers and electronic health records.
Clearinghouses
entities that receive, review, send, and manage insurance claims for physicians
EHR
Electronic Health Record
4 parts to HIPAA’s administrative simplification
- Electronic transactions
- Privacy requirements
- Security requirements
- National identifier requirements
What is the recommended fee for reproducing medical records?
No more than $1/page, or $100 for entire record
Things to remember regarding releasing medical records
- 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
6 important factors of how medical records shoudl be kept
- Easily retrievable
- Kept in an orderly manner
- Complete
- Legible
- Accurate
- Brief
Flow sheet
Designed to limit the need for long handwritten care notes; info is recorded in graphic or table form
Progress notes
Statements about various aspects of patient care; reflects each encounter with patient chronologicallyp
What should be done with reports before they are added to the medical record?
Should be read and initialed by the physician before they are added to the chart
4 steps to ensure efficient and speedy filing and document retrieval
- 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
3 classes of medical records
Active, inactive or closed
Inactive records
- PT has not been in office in 2-3 years
- still kept in office
Closed records
-Have terminated their relationship with physician due to moving, termination by physician, or death
When is statute of limitations up for minors?
Until child reaches legal age in every state
SOAP
Subjective
Objective
Assessment
Plan
POMR
Problem
Oriented
Medical
Record
HIPAA officer
Coordinates and oversees the various aspects of compliance
Workers comp cases should be kept open for how long after last date of treatment?
2 yrs.
Master patient index
A cross reference in numeric filing
5 Responsibilities of HIPAA officer
- 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
Patient authorization
- release only info relating to specific disorder
- specify time limit
- drug, alcohol, and std info must be specifically listed to release info
All physicians with Medicare/Medicaid patients must be using EHR by the year…..?
2017
