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health records > final > Flashcards

final Flashcards

1
Q

medical care act 4 criteria 1966 PCPU

A

federal legislation. public administration, comprhensive coverage, universality, portability

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2
Q

canada health act 5 criteria 1984 PCPUA

A

federal legislation, public adminstration, comprehensive coverage, universality, portability. ACCESIBILITY

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3
Q

primary health care

A

care provided ar first contact with provider in ambulatroy care setting,

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4
Q

3 essential services of primary health care

A

guardian-gatekeeper, chronicler

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5
Q

caregiver who is funded by government?

A

doctors..sometimes dentists in gov sponsered clinics

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6
Q

4 important reports?

A

Kirby-2002, Romanow-2002, saskatchewan caring for medicare-fyke-2001, Saskatchewan healthy people. a healthy province

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7
Q

important points-The health of Candians- the federal role, kirby, 2002

A

service-based funding, wait time, protection from drug costs, 24 hour service, development of ehealth record, MORE PRIVATE FUNDING

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8
Q

future of healthcare aka Romanow Report, 2002. 11 points

A

47 recommendations, 11 areas.

  1. sustaining medicare
  2. health care, citizenship, federalism
  3. info, ideas, evidence
  4. investing in health care providers 5.primary health care and prevention
  5. imporving access, ensuring quiality
  6. rural and remote commmunities
  7. home care: the next essential service
  8. prescription drugs
  9. new approach to aborignal health
  10. health care and globalization
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9
Q

Saskatchewan health ppl healthy province

A 
based on fyke recommendations
telehealth
different categories of hospitals
reduce surgery wait times
funding for training health providers
funding for emts
form 12 regional health authorities
create health quiality council
increase funding for health research
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10
Q

8uses of health record

A
  1. direct patient care
  2. review professional practice
  3. education
  4. reasearch
  5. admin/management functions
  6. reimbursment
  7. lega; interests
  8. legislation and accedidation
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11
Q

impersonal vs personal

A

impersonal-idenitiy of patient is not of primary importance

personal-identity of patient is retain and is important because of the info of a specific patient

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12
Q

conccurrent vs retrospective

A

concurrent-used during provison of services for an inpatient or during ongoing outpatient treatment
retrospective-used for any purpose after serive has been provided or after patient treatment is complete

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13
Q

5 ways a client can access info from HIM department

A 
direct access
reporting forms
telephone
photocopying
fax
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14
Q

who can give consent for TREATMENT

A

parent of a minor
legal guardian
surviving spouse
next of kin

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15
Q

Review hospital standards regulations

A

sfs

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16
Q

Physician document on what?

A

Physician orders, consults, operative, history and physical, discharge.. Progress notes

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17
Q

department docuimentation and forms

A

admisison/registration- admission discharge form
medical staff-psychian orders, consultations, operative report, anesthetic report, pathology, progress notes, autoopsy
diagnositc imagin- xray, ct,ultrasound,mri, nuc medicine

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18
Q

Forms committee

A

A part of the health record info committee…
Must be. Member of him, med staff, nursing staff
Him members must take ACTIVE ROLE
eligible to vote n hold office,

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19
Q

Computer forms

A 
Logical sequence
Field edits 
Eye catching by use of color
Simple and easy to use
Menus with alternative answers
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20
Q

Forma committee purpose?

A 
Review purposes forms
Review already in use forms
Recommend revisions
Consistent with standard specs 
Discontinuation
Control handle and distribution
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21
Q

Qa death chart

A

Med documentation stating who pronounced patient, date, time

Nursing documentation. Apparent tomf of death

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22
Q

AMA

Elopement

A

Against medical advice- signed out

Elopement is running away, not telling anyone

23
Q

Incomplete vs deliguient chart

A

21 days vs over 21 days

24
Q

Concurrent qa?

A

Qa done on nurse unit during patient stay by him

25
Q

What is MPI? Primary use?

A

Master patient index/ master person index
Catalogue or database containing info on all patients treated in a health care facility

KEY TO LOCATING PATIENT CHART IN FILING OR COMPUTER SYSYEM
FACILITATE RETRIEVAL OF PATIENT RECORD

26
Q

6 digit terminal digit filing

A 
6725=
6 tertiary
72 secondary
5 primary/ terminal
Read from right to left, separated into 3 parts.  100 primary filing sections
27
Q

Unit numbering?

A

One number on all patient documentation
One number in MPI
great for large facilities
Admissions are filed together

28
Q

Methods of storage

A

File cabinets- expensive and take up space
Open shelves- most practical efficient, hold more charts less expensive ( stationary, moveable)
Automated- expensive, power failure, reduces time and energy

29
Q

How many hours must the pt history, physical exam and provisional diagnosis be done within admission?

A

48 hours

30
Q

If a patient is re admitted within– days… With same diagnosis — will suffice as history and physical?

A

30 days

Results..

31
Q

Discharge summary must be completed within —- days of seperation?

A

7 days

32
Q

What info must be recorded for each outpatient visit?

A 
Patient id
Chief complain
History and physical 
Prenatal report if applicable 
Provisional diagnosis
Final diagnosis 
Condition on discharge/transfer
Summary of services
Original and signed reports
Graphic charts, progress notes
Certification of death
Post mortem if applicable
33
Q

48

A

.

34
Q

Health record shall be signed and completed within — days of seperation?

A

21 days

35
Q

Surgical operation must not be preformed without???? Except in emergency

A

Complete history
Physical exam
Preoperative diagnosis

36
Q

Record of operatic. Must be prepared and signed within – hours?

A

48 hours

37
Q

JURSI??

A

Junior undergraduate rotating student intern

38
Q

Who is a JURSI?

A

Receiving instruction in final year of school

Name appears on educational. Registrars of college of physicians and surgeons in Sask

39
Q

Requirements of physicians orders?

A

Recidered in ink
Signed
Part of health record

40
Q

2 conditions newborns must be tested for?

A

PKU Phenyketonuria

Hypothyroidism

41
Q

How long does a hostlpital have to retain a record?

A

Min 10 years or until patient is 19
Whichever is longer
If microfilms is to be done. Original must be retained 6 years and microfilm must be kept for remainder of retention period

42
Q

8 examples of tissues that are an exception to law of being forwarded to pathologist

A

Tooth, tonsil, prepuce, harmorrhoid, hernial sac, finger, toe, hand, foot, arm, leg removed or amputated

43
Q

What must be completed when a hospital discharges a patient for transfer to another hospital?

A

Interfacility transfer form

44
Q

What rights does HIPA give?

A

Consent to use and disclose
Revoke consent of collection and use or disclosure
Be informed of how info will be used
Ask that their info be amended if there is an error or omission

45
Q

Mental service act?

A

Records are property of facility
No person can disclose info of a patient
Can disclose for legal reason or if minister orders

46
Q

Freedom of info and protection of privacy act

A

Allows pol to access info in possession of hospital, board of Ed, care home.

Rules about how personal info can be collected and used

47
Q

Privacy act federal!

A

Places limits on collect use and disclosed
Gives individual right to access and correct personal info about them selves.. Not just health info.. Employee files, credit records.. Loan record, is numbers, income, age? Blood type

48
Q

Categories of medical staff? 6

A

Active- doc who delivers most services in region
Associate- doc in probation period
Limited-doc in care home
Assistant- docs do not admit patients , DON’T VOTE
Visiting- active in another region- DON’T VOTE, NON MEMBER
Honorary- old docs., don’t sdmit it vote, or hold office

49
Q

Committee that and him is a member

A 
Credentials committee
Health record committee
Quality assurance committee
Tissue committee 
Utilization. Review committee
50
Q

What is CHIMA?

A

Canadian health info management association

51
Q

CHIMA vision??

A

Advancing the health care system as the change leader in health information management

52
Q

What is a ppb? And use?

A

Professional practice brief

53
Q

3 domains of practice??

A

eHIM
Privacy
Data quality

54
Q

Ppb?

A

Written to reflect a national perspective

health records (1 decks)

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