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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

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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

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3
Q

Chief complaint

A

The main reason the patient sought care today

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4
Q

Chronological

A

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

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5
Q

Clear

A

To the point and easily understood

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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

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7
Q

Complete

A

Containing all necessary information

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8
Q

Concise

A

Containing only the necessary information, nothing more

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9
Q

Correct

A

Accurate

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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

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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

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12
Q

Electronic signature

A

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

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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

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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

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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.

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16
Q

Indecipherable

A
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17
Q

Medical information

A

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

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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

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19
Q

Narrative chart note

A

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

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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

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21
Q

Obliterated

A

Completely marked out so that the original is unrecognizable

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22
Q

Personal information

A

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

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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.

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24
Q

Progress notes

A

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

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25
Q

Purge

A

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

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26
Q

Shingling

A

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

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27
Q

SOAP note charting

A

Subjective, objective, assessment and plan; a common form of charting in the medical record where clinicians chart information in an easy to find format

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28
Q

Social information

A

Information in a patient’s chart relating to his or her social status, such as smoking or participating in high-risk behaviors

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29
Q

Standard of care

A

The amount and type of care a reasonable and prudent person would provide, given the same training and circumstances

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30
Q

Statute of limitations

A

The period of time provided by law for a patient to file a malpractice lawsuit from the date of the injury

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31
Q

Subpoena

A

A legal document that requires a medical office to release medical records or provide court testimony

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32
Q

Medical record is a legal document

A

Most important tool to defend against a malpractice suit

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33
Q

Patient doesn’t want to share information

A

Let the patient know the record is confidential
Still won’t, notify physician
Won’t for physician, physician may choose not to treat

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34
Q

Financial information is kept separate from medical information

A

Medical record information must be released on request or with court order

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35
Q

Chart includes

A

HIPAA form
Information releases
Documents from hospitalizations
Any items the patient brings to an appointment

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36
Q

Medical chart rules

A

5 Cs
Concise
Complete
Clear
Correct
Chronological

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37
Q

Sign off on medical record

A

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
Q

Keep chart notes professional

A

Objective
Never contain conjecture or opinion
Proper spelling and grammar

39
Q

Abbreviations

A

Joint commission has published a list of abbreviations that should never be used

40
Q

Chart communications with patients

A

Phone calls
Emails
Missed or cancelled appointments
Pharmacy requests
Should have an office policy
Be thorough protects office from malpractice

41
Q

Alphabetic filing

A

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
Q

Numerical filing

A

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
Q

Locating missing files

A

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
Q

Shredding companies

A

Provide certifying notices

45
Q

Medicare retention guidelines

A

Medical records must be retained for at least 5 years

46
Q

Medicare managed care plan retention

A

No less than 10 years

47
Q

HIPAA legislation retention

A

No less than 6 years from the last date of treatment

48
Q

Specific states retention

A

May vary
Keep as long as possible in case of lawsuits

49
Q

Corrections

A

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
Q

Late entry

A

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
Q

Charting conflicting orders

A

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
Q

Ownership of medical Record

A

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
Q

EMR/EHR

A

At Mayo Clinic since 1960s
2004- GW Bush - computerize health records
Plan for 2014
By 2017-87% providers use EHR

54
Q

Releasing medical records

A

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
Q

Information to release

A

Make sure file is complete and that it only contains information about the patient. Obliterate any non-patient-specific information before sending copies

56
Q

Subpoenaed medical records

A

Don’t have to tell patient
Must keep records of all disclosures

57
Q

Release original medical records

A

Usually subpoena
Make copy of everything to keep in office as proof of the contents at time of release

58
Q

Release information when physician leaves the practice

A

Patient must be notified
Give them time to request transfer
Estate responsible for the original files for the period outlined by the state

59
Q

Minor’s med info

A

Laws vary from state to state
May receive copies of only things their parents can’t see
Age 18 for majority

60
Q

Super-protected medical information

A

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
Q

1986 National Childhood Vaccine Injury Act

A

Report patient name and age
Also name of vaccine and lot number
The call must be documented in the patient file

62
Q

Cases of abuse

A

Must report abuse cases
Gunshot wounds
Assault
Rape
Can’t be sued for reporting
Failure to report may allow charges against the provider

63
Q

Illnesses and injuries to be reported

A

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
Q

Durable power of attorney

A

Names people to speak or act for the patient
Usually concerns life support but can sign contracts and access bank accounts

65
Q

Faxing medical records

A

Only if no other data transfer is available
Only if mail or messenger won’t suffice
Use HIPAA compliant fax cover sheet

66
Q

Improper disclosure of medical records

A

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
Q

Payroll

A

The process of calculating the amounts employees receive for their work

68
Q

Gross pay

A

Amount earned before taxes or deductions are subtracted

69
Q

Outsource

A

To send outside a business to another business for completion

70
Q

Must keep track of local and national laws for payroll

A
71
Q

Payroll taxes

A

Monies withheld from wages for federal income, Social Security, and Medicare obligations

72
Q

Deductions

A

Number of allowances to be withheld from an employee’s wages

73
Q

Wages

A

Monies paid for work performed

74
Q

Net pay

A

Amount of wages remaining after deductions and taxes have been subtracted

75
Q

Quarterly payroll reports

A

Documents that specify the taxes withheld from wages quarterly

76
Q

Penalty for improper disclosure

A

Fines or written warnings
HIPAA fines $100-$25000

77
Q

Wrongful disclosure

A

Up to $50000
Imprisonment up to a year

78
Q

False pretense

A

Up to $100,000
Up to 5 years

79
Q

Intent to sell or transfer for commercial purposes

A

Up to $250,000
Up to 5 years

80
Q

Refill requests

A

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
Q

FICA

A

Federal insurance contributions act
law that addresses social security withholding taxes

82
Q

FUTA

A

Federal unemployment tax act
Law that addresses federal unemployment tax withholdings

83
Q

Unemployment insurance

A

Program that pays employees who have lost their jobs

84
Q

Social Security Act

A

1- elderly, survivors and disability insurance
2-hospital insurance known as Medicare

85
Q

FICA tax

A

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
Q

FICA cap

A

As of 2017
After $125,000 no longer subject to FICA tax
Medicare- no wage limit

87
Q

Auditors

A

People who review personal or corporate bank or tax records on behalf of an agency like the IRS

88
Q

IRS tax

A

Employers file quarterly

89
Q

Reception area

A

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
Q

Reception furniture

A

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
Q

Medical research programs

A

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
Q

Personnel records

A

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.

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