Chapters 1-3 Flashcards
What is the purpose of date and time stamping in medical transcription?
A. To allow reimbursement
B. To help create an audit trail
C. To indicate the date treatment was provided
D. To identify the transcriptionist
B
Which expression is included in the record to meet HIPAA security requirements?
A. AXIS II
B. T1NXMX
C. T: 12/31/11, 1500
D. Dictated but not read.
C
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
What does PHI stand for under the HIPAA definition?
Protected Health Information
According to HIPAA, PHI includes a information in what form?
On paper, electronically transmitted, and orally transmitted
Which would be a violation of the HIPAA privacy rule?
A. Releasing information relating to patient’s care to a third-party insurance billing company.
B. Disclosing information about an individual’s health in a phone call.
C. Releasing information about a patient’s health status to public health authorities.
D. Using de-identifying health record for clinical study or statistical research.
A
Which individual is considered an accountable party under HIPAA?
A. An employee of a covered entity.
B. An employee of a transcription service.
C. A business associate of a covered entity.
D. An employee of a federally funded healthcare facility
C
According to the Joint Commission, an admitting history and physical examination must be completed no more than _____ hours of inpatient admission?
Within 24 hours
What typical TAT is established by most facilities for dictation of a discharge summary?
30 days
What is the “Basic Four” acute care document types
- History and physical
- Consultation reports
- Operative reports
- Discharge summaries
ADT refers to ______data?
Admission/Discharge/Transfer
According to HL7, what should be done to a dictated addendum?
Transcribed in a new document with its own document ID
The process by which a provider verifies what has been captured in the record and affixes their signature to the report is called:
Authentication
What is FULL BLOCK FORMATION?
All text begins flush with the left margin (date, address, reference line, salutation).
What is MODIFIED BLOCK FORMAT?
Date, complimentary close, and signature line are placed just to the right of middle.
In a document, What heading information are required to be listed vertically?
Chief complaint Diagnosis Preoperative diagnosis Postoperative diagnosis Names of operations.
All phrases end with a period with the exception of?
Date or the name of a person (NO period)
What is syntax?
Word arrangement. ESL dictators are particularly prone to errors in syntax.
Jargon
The technical terminology or characteristic idiom of a special activity or group. Eg., premie, urines, orthopedist
Medical jargon tends to be imprecise and may be offensive and derogatory. Only use in quotes
Brief forms
Shortened forms of common words that are acceptable to transcribe in abbreviated format.
Acceptable: exam, lab, prep, monos, basis, lymphs, eos
Unacceptable: appy, crit, epi, flex sig, lab Chloe
Back Formations
New words formed by altering an existing word.
Use if they have become accepted through wide-spread use.
Acceptable: diagnosis - to diagnose; Bovie - bovied
Unacceptable: adhesion - adhese; liaison - to liase; orchiopex - pep
What is a covered entity?
Those that generate individually identifiable patient health information and therefore have primary responsibility for maintaining the privacy and confidentiality of this information.
E.g.,
Most health plans
Healthcare clearing houses.
Healthcare providers that transmit any health information in electronic form in connection with certain administrative transactions related to payment for health care i.e., Hospitals, nursing homes, clinics, physicians offices,
Permitted disclosures
Covered entities can disclose PHI for treatment, payment, or healthcare operations without any prior consent/authorization from patient.
