Final Exam Flashcards
Ethical decision making
- process that requires striking a balance between science and morality
- making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong
American Nurses Association (ANA) - Code of Ethics for nurses with Interpretive statements
- provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT (health information technology)
Bioethical standards
Autonomy Freedom Veracity Privacy Beneficence Fidelity
-all are maximally appropriate to the health care setting
Autonomy
- the right to choose for himself or herself
- respecting clients opinions, perspectives, values, & beliefs
Freedom
- the ability of an individual to act independently w/o coercion or constraint in ones choice and action
Veracity
- being completely truthful with patients
- a patient’s right to truth
Privacy
- the right to be left alone when you want to be
- to have control over your own personal possessions
- the right to not be observed w/o your consent
Beneficence
- actions performed that contribute to the welfare of others
- action of doing good or right by and for the patient
Fidelity
- right to what has been promised
- keeping to one’s promise
Telehealth
- use of electronic information and telecommunications technologies to support:
- long-distance clinical healthcare
- patient and professional health-related education
- public health
- health administration
technologies include:
- videoconferencing
- the internet
- store-and-forward imaging
- streaming media
- terrestrial & wireless communications
Telemedicine
- remote clinical health services
mHealth
- Mobile health
- the practice of medicine and public health supported by mobiles devices such as:
- mobiles phones
- tablets
- personal digital assistants
- the wireless infrastructure
- the use of wireless communication to support efficiency in public health and clinical practice
Mobile Medical Applications (Apps)
- accessories to a regulated medical device or are software that transforms a mobile platform into a regulated medical device
- facilitates mHealth
Medical devices
- any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients
Rationale APP is NOT considered medical devices
Apps that are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease
FDA Oversight for Medical Devices
- regulatory body that oversees mobile apps that are medical devices and whose functionality could pose a risk to a patient’s safety if the mobile app were to not function as intended
- also oversees the cybersecurity management of these devices as well as the hospital network security
Point of care (POC)
- testing and diagnosis at the patient’s side and can be conducted anywhere the patient is such as:
- home
- -physician office
- -ambulance
- -hospital bedside
Privacy
- practice of maintaining the security and confidentiality of patient records
Confidentiality
- the act of holding information in confidence, not to be released to unauthorized individuals
Cybersecurity
- measures taken to protect a computer or computer system against unauthorized access or attack
- FDA is main regulatory agency
Computer-aided translators
- language translation in which a human translator uses computer hardware to support and facilitate the translation process
Health Insurance Portability and Accountability Act (HIPPA)
- enacted in 1996
- federal law that required the creation of national standards to protect sensitive patient health information from being disclosed w/o the patient’s consent or knowledge
ICD-10 Codes
- alphanumeric codes used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses
- shorthand for the patient’s diagnosis, which are used to provide the payer information on the necessity of the visit or procedure performed
Current procedural terminology (CPT)
- official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non-physician providers
Evaluation and Management Coding (E/M coding)
- process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing
Necessity for establishing E/M codes
- place of service
- type of service
- patient status
Components of risk-based E/M coding
- history
- physical
- medical decision making
Medical decision making (MDM)
- 1 of 3 components to establishing E/M codes
- way of quantifying the complexity of thinking that is required for the visit
3 key elements to medical decision making
- risk
- data
- diagnosis
Reimbursement coding
- claims and documentation filed by providers using medical diagnosis and procedure codes
- assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders
Clinical support tools
- found in EHR software that when applied effectively can:
- enhance patient care quality and outcomes
- improve efficiency
- help to ensure regulatory compliance
- process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient-specific:
- interventions
- assessments
- other forms of guidance for clinicians, patients, and others involved in care delivery
Alert fatigue
- main challenge to effective implementation of CDS tools
