Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

2601 > Chpt 6 > Flashcards

Chpt 6 Flashcards

1
Q

Active patient file

A

Medical record for a patient who is actively treated in the medical office

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Advance directive

A

A legal document that outlines a patient’s desire regarding life-sustaining treatment or names a guardian to speak for the patient
Living wills - state patient desire should they become incapacitated
DNR must be written and signed by the patient’s doctor- keep copy in patient file
Concealing or altering an advance directive is a misdemeanor
Creating an advance directive falsely is a felony

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Chief complaint

A

The main reason the patient sought care today

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Chronological

A

The order in which events occur in time, from oldest to newest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Clear

A

To the point and easily understood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Closed patient file

A

Medical record for a patient who has moved out of the area, is deceased, or has indicated indicated that he will not be returning for care
Usually moved to other storage facilities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Complete

A

Containing all necessary information

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Concise

A

Containing only the necessary information, nothing more

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Correct

A

Accurate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Cross-referencing

A

A process for locating files when a patient may go by one or more last names
Use place cards
In electronic files use birthdates

Must have policies in place on hyphenated names

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Discovery rule

A

Relates to when an injury was discovered, rather than when the injury occurred ; the statute of limitations may begin from the date the injury was discovered or should have been discovered

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Electronic signature

A

An electronic version of a person’s signature, used in the electronic medical record

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Financial information

A

Items in the medical record pertaining to the patient’s insurance coverage and account status
Copies of insurance company information
Signed authorizations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Flowchart

A

A chart used in the medical record to document the progress of growth, such as child height, weight and head circumference

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Inactive patient file

A

Patient file for a patient who has not been seen in a certain period of time , but who will likely return one day.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Indecipherable

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Medical information

A

Information in the patient’s medical record pertaining to his or her medical history or condition
Includes chief complaint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Medical record

A

A record of the patient’s healthcare
Full account
What treatment given and why
Notation if patient refuses care
Should not contain opinions or judgments
Write as if the patient will be reading it

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Narrative chart note

A

Written description of a patient’s visit; the oldest form of medical note taking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Nontherapeutic research

A

Medical research that does not have therapeutic value to the patient
Dispense medication to healthy people so as to identify any side effects- must have signed consent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Obliterated

A

Completely marked out so that the original is unrecognizable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Personal information

A

Information pertaining to the patient, such as address and telephone number

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Problem-oriented medical record (POMR) charting

A

A charting process that allows providers to assign a number to each medical problem and chart each item each time the patient is seen for care.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Progress notes

A

The daily chart notes taken at the time of a patient’s visit to a clinic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Purge
To go through files and remove the items or charts that are old or no longer needed Must have a clear policy on what constitutes closed or inactive Move files or put on media and shred
26
Shingling
The process of taping small pieces of paper to a full size sheet of paper so that small items are not lost in the chart. A
27
SOAP note charting
Subjective, objective, assessment and plan; a common form of charting in the medical record where clinicians chart information in an easy to find format
28
Social information
Information in a patient’s chart relating to his or her social status, such as smoking or participating in high-risk behaviors
29
Standard of care
The amount and type of care a reasonable and prudent person would provide, given the same training and circumstances
30
Statute of limitations
The period of time provided by law for a patient to file a malpractice lawsuit from the date of the injury
31
Subpoena
A legal document that requires a medical office to release medical records or provide court testimony
32
Medical record is a legal document
Most important tool to defend against a malpractice suit
33
Patient doesn’t want to share information
Let the patient know the record is confidential Still won’t, notify physician Won’t for physician, physician may choose not to treat
34
Financial information is kept separate from medical information
Medical record information must be released on request or with court order
35
Chart includes
HIPAA form Information releases Documents from hospitalizations Any items the patient brings to an appointment
36
Medical chart rules
5 Cs Concise Complete Clear Correct Chronological
37
Sign off on medical record
Each entry must have an identifying mark indicating the person who made the entry Minimum initials, credentials & date Can have electronic or rubber stamp signaturea
38
Keep chart notes professional
Objective Never contain conjecture or opinion Proper spelling and grammar
39
Abbreviations
Joint commission has published a list of abbreviations that should never be used
40
Chart communications with patients
Phone calls Emails Missed or cancelled appointments Pharmacy requests Should have an office policy Be thorough protects office from malpractice
41
Alphabetic filing
By last name Color coding to find misplaced charts - use 1st 2 letters of last name or patient’s first and last initials or portion of last name and first initial
42
Numerical filing
Masks the identity of patients Difficult to retrieve the files without the proper code. For sensitive medical offices Need a list of patients and corresponding codes
43
Locating missing files
Try last name Try first name Try other patients from the date last seen With electronic records it may be impossible to find missing information , must rerequest
44
Shredding companies
Provide certifying notices
45
Medicare retention guidelines
Medical records must be retained for at least 5 years
46
Medicare managed care plan retention
No less than 10 years
47
HIPAA legislation retention
No less than 6 years from the last date of treatment
48
Specific states retention
May vary Keep as long as possible in case of lawsuits
49
Corrections
Paper-draw a line through, initial and date and write correction above or beside the line Multiple lines- strike through with a single line with a notation , date, initials and credentials Errors should be corrected by the one who made it
50
Late entry
Addition made Start with date of the visit the note pertains to Followed by ‘Late entry’ Then signature If no room add Addendum to (date of visit) Electronic record: changes will be reflected the date of entry and not overwrite original
51
Charting conflicting orders
Don’t agree with an order Check with physician If he says leave it the way it is document in chart Include what you told doctor and his response
52
Ownership of medical Record
Physician or facility where created Information belongs to patient- they can access and correct records - their written statement becomes a part of the permanent record if the physician is unwilling to make a correction
53
EMR/EHR
At Mayo Clinic since 1960s 2004- GW Bush - computerize health records Plan for 2014 By 2017-87% providers use EHR
54
Releasing medical records
Patient confidentiality at forefront Only release information with patient consent-even to insurance companies Every request must have patient’s signed authorization-confirm this is to the right facility-be clear about the nature of the request Some physicians want to be told about requests
55
Information to release
Make sure file is complete and that it only contains information about the patient. Obliterate any non-patient-specific information before sending copies
56
Subpoenaed medical records
Don’t have to tell patient Must keep records of all disclosures
57
Release original medical records
Usually subpoena Make copy of everything to keep in office as proof of the contents at time of release
58
Release information when physician leaves the practice
Patient must be notified Give them time to request transfer Estate responsible for the original files for the period outlined by the state
59
Minor’s med info
Laws vary from state to state May receive copies of only things their parents can’t see Age 18 for majority
60
Super-protected medical information
Varies from state to state Relates to family planning, STIs, HIV, mental illness, drug rehabilitation Requires a separate authorization before it can be released to a third party
61
1986 National Childhood Vaccine Injury Act
Report patient name and age Also name of vaccine and lot number The call must be documented in the patient file
62
Cases of abuse
Must report abuse cases Gunshot wounds Assault Rape Can’t be sued for reporting Failure to report may allow charges against the provider
63
Illnesses and injuries to be reported
Anthrax Certain STIs Dog bites Each state determines the length of time the provider has to report after seeing the patient- some same day some within 2 weeks
64
Durable power of attorney
Names people to speak or act for the patient Usually concerns life support but can sign contracts and access bank accounts
65
Faxing medical records
Only if no other data transfer is available Only if mail or messenger won’t suffice Use HIPAA compliant fax cover sheet
66
Improper disclosure of medical records
Cause for a lawsuit Must be reported by office to the Office of Civil Rights Patients may contact OCR if they think information has been improperly disclosed Office must keep proper forms and help patient file
67
Payroll
The process of calculating the amounts employees receive for their work
68
Gross pay
Amount earned before taxes or deductions are subtracted
69
Outsource
To send outside a business to another business for completion
70
Must keep track of local and national laws for payroll
71
Payroll taxes
Monies withheld from wages for federal income, Social Security, and Medicare obligations
72
Deductions
Number of allowances to be withheld from an employee’s wages
73
Wages
Monies paid for work performed
74
Net pay
Amount of wages remaining after deductions and taxes have been subtracted
75
Quarterly payroll reports
Documents that specify the taxes withheld from wages quarterly
76
Penalty for improper disclosure
Fines or written warnings HIPAA fines $100-$25000
77
Wrongful disclosure
Up to $50000 Imprisonment up to a year
78
False pretense
Up to $100,000 Up to 5 years
79
Intent to sell or transfer for commercial purposes
Up to $250,000 Up to 5 years
80
Refill requests
Have 24 hours policy When requesting a refill the nurse must pull the patient’s file and give the file and request to the doctor for review Ehr nurse enters request and forwards to physician If physician wants to see the patient first the nurse calls pharmacy to delay then calls patient to schedule appointment Chart all information about the refill in that chart
81
FICA
Federal insurance contributions act law that addresses social security withholding taxes
82
FUTA
Federal unemployment tax act Law that addresses federal unemployment tax withholdings
83
Unemployment insurance
Program that pays employees who have lost their jobs
84
Social Security Act
1- elderly, survivors and disability insurance 2-hospital insurance known as Medicare
85
FICA tax
Started at 1% Now 5.65% Employees pay 4. 2% of gross income and 1.45% for Medicare Employers pay 7.65% of wage amount creating a deposit for each employee at 13.3% of their gross payrolls
86
FICA cap
As of 2017 After $125,000 no longer subject to FICA tax Medicare- no wage limit
87
Auditors
People who review personal or corporate bank or tax records on behalf of an agency like the IRS
88
IRS tax
Employers file quarterly
89
Reception area
Quiet and peaceful ask children to be quiet Ask patients to take food outside May segregate sick patients Area for children Keep toys safe for all ages- easy to clean, no sharp edges State law in some states (Washington) clean with 10% bleach solution after each use Reading material should reflect demographic
90
Reception furniture
Seating to accommodate at least 1 hours worth of patients per physician and their families Ar a level that patients can rise easily Some oversized chairs
91
Medical research programs
A medical program geared towards researching a particular condition or treatment Must keep patient files indefinitely-to prove consent in case of future problems
92
Personnel records
Should reflect all changes to employees employment status-raises, evaluations, disciplinary actions, CEUs, marital status changes, tax exemptions Accurate and up-to-date Run background checks periodically in case something has changed.

2601 (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions