Chapter 9 - Legal Health Record: Maintenance, Content, Documentation, and Disposition

Question 1

disposition (medical)

Answer 1

1. a tendency, either physical or mental, toward a given disease.
2. the prevailing temperament or character, giving a degree of predictability to the response to a situation or other stimulus.
3. the plan for continuing health care of a patient following discharge from a given health care facility.
4. transfer to the care or possession of another
5. the act or the power of disposing of something or the state of being disposed of
6. the way in which something is placed or arranged, especially in relation to other things

Question 2

temperament

Answer 2

a person’s or animal’s nature, especially as it permanently affects their behavior

Question 3

designated record sets

Answer 3

another name for medical records, including medical records, billing records, payment and claims records, health plan enrollment records, case management records, as well as other records used, in whole or in part, by or for a covered entity to make decisions about individuals.

Question 4

subsidiary (adjective)

Answer 4

1. furnishing aid or support
2. of secondary importance
3. of, relating to, or constituting a subsidy

Question 5

auxiliary

Answer 5

offering or providing help or functioning in a subsidiary capacity

Question 6

ancillary report

Answer 6

Reports from various treatments and therapies the patient has received such as rehabilitation, social services or respiratory therapy

Question 7

subsidiary (noun; business)

Answer 7

a company wholly controlled by another

Question 8

subsidy

Answer 8

a grant or gift of money

Question 9

Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA)

Answer 9

a federal and state law that states that accurate copies of business records are acceptable in court

Question 10

physician order

Answer 10

an order for a medical intervention given by a physician, it can be verbal or written

Question 11

attestation

Answer 11

the applying of a signature to documentation, thus showing authorship

Question 12

rubber signature stamp

Answer 12

a stamp that contains an individual’s signature; it can be used in certain cases by law to sign documents

Question 13

ISO (International Organization for Standardization)

Answer 13

an international standard-setting body composed of representatives from various national standards organizations

Question 14

ASTM (American Society for Testing and Materials)

Answer 14

an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services

Question 15

countersignature

Answer 15

a signature by a second provider or supervising medical professional of a first provider’s documentation; it is used a lot in teaching hospitals because the attending physician is still in training, and needs someone else to review and sign off on his documentation

Question 16

auto-attestation

Answer 16

also called auto-authentication; it is the automatic signing of a document in a doctor’s name when that doctor fails to review and actively approve or disapprove of an entry into an electronic health record; some systems allow this, but it is not allowed by the Joint Commission, Medicare Conditions of Participation, or the Uniform Electronic Transactions Act.

Question 17

batch signing

Answer 17

the act of attesting to (signing) multiple documents at one time; it is only considered acceptable if each document can be viewed and acted upon individually

Question 18

medical scribe

Answer 18

a person, or paraprofessional, who specializes in charting physician-patient encounters in real time, such as during medical examinations. They also locate information and patients for physicians and complete forms needed for patient care. Depending on which area of practice the scribe works in, the position may also be called clinical scribe, ER scribe or ED scribe (in the emergency department), or just scribe (when the context is implicit). A scribe is trained in health information management and the use of health information technology to support it.

Question 19

paraprofessional

Answer 19

a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional

Question 20

late entry

Answer 20

an entry in a health record that is entered in at a time much later than when it was supposed to be put in

Question 21

iteration (adjective: iterative)

Answer 21

the repetition of a process in order to generate a sequence of outcomes. Each repetition of the process is a single iteration, and the outcome of each iteration is then the starting point of the next iteration

Question 22

delineation

Answer 22

the act of outlining or representing something with lines or words

Question 23

concurrent analysis (healthcare)

Answer 23

the review of a medical record by health information management staff during the patient’s stay in a healthcare organization to determine whether signatures or other pertinent information are missing

Question 24

patient matching

Answer 24

accurately connecting a patient to his or her medical information

Question 25

deterministic algorithm

Answer 25

an algorithm that compares values in various database fields (e.g. date of birth, race, martial status) to detect exact or partial matches; used to prevent duplicate health records

Question 26

statistical/mathematical algorithm

Answer 26

an algorithm that assigns weights to data that nearly match, determining the probability that two records are those of the same patient; used to prevent duplicate health records

Question 27

active vs inactive records

Answer 27

Active records are health records that are used or consulted routinely, generally because the patient encounters are still taking place. Inactive records are those that are not used often, generally because patient encounters have ceased and they must be retained because the required retention period has not expired.

Question 28

voluminous

Answer 28

(1) having or marked by great volume or bulk
(2) filling or capable of filling a large volume or several volumes
(3) writing or speaking much or at great length
(4) consisting of many folds, coils, or convolutions

Question 29

convolution

Answer 29

(1) a form or shape that is folded in curved or tortuous windings
(2) one of the irregular ridges on the surface of the brain and especially of the cerebrum of higher mammals
(3) a complication or intricacy of form, design, or structure

Question 30

degaussing

Answer 30

the process of removing magnetism from something, often used to destroy hard drives

Question 31

de novo

Answer 31

From Latin, meaning “from the new.”
When a court hears a case de novo, it is deciding the issues without reference to any legal conclusion or assumption made by the previous court to hear the case

Question 32

mittimus

Answer 32

a warrant issued to a sheriff commanding the delivery to prison of a person named in the warrant

Question 33

rehabilitate

Answer 33

(1) to restore to a former capacity
(2) to restore to good repute: reestablish the good name of
(3) to restore to a former state (as of efficiency, good management, or solvency) (e.g. rehabilitate slum areas)
(4) to restore or bring to a condition of health or useful and constructive activity

Question 34

stipulate

Answer 34

(1) to make an agreement or covenant to do or forbear something
(2) to demand an express term in an agreement—used with for
(3) to specify as a condition or requirement (as of an agreement or offer)
(4) to give a guarantee of

Question 35

tantamount

Answer 35

equivalent in value, significance, or effect (e.g. a relationship tantamount to marriage)

Question 36

variance

Answer 36

(1) the fact, quality, or state of being variable or variant
(2) the fact or state of being in disagreement
(3) a disagreement between two parts of the same legal proceeding that must be consonant (being in agreement or harmony)
(4) a license to do some act contrary to the usual rule

Question 37

mitigation

Answer 37

the process or result of making something less severe, dangerous, painful, harsh, or damaging

Question 38

prima facie

Answer 38

at first view, on the first appearance

legally sufficient to establish a fact or a case unless disproved (e.g. prima facie evidence)

Question 39

proportionality

Answer 39

a general principle in law which covers several special (although related) concepts.

The concept of proportionality is used as a criterion of fairness and justice in statutory interpretation processes, especially in constitutional law, as a logical method intended to assist in discerning the correct balance between the restriction imposed by a corrective measure and the severity of the nature of the prohibited act.

Within criminal law, it is used to convey the idea that the punishment of an offender should fit the crime.

Under international humanitarian law governing the legal use of force in an armed conflict, proportionality and distinction are important factors in assessing military necessity.

Question 40

proportionate

Answer 40

another term for proportional

Question 41

proportional

Answer 41

corresponding in size or amount to something else,

referring to proportionality