health record

Question 1

Health Record

Answer 1

-Legal document
-Attests to the care given to a patient
-Recapitulation of all patient care events
-Single record
-Paper or computer based

Question 2

Health Data Management Department

Answer 2

-Functions to maintain the system to store and retrieve clinical information on every patient
-Maintained in 1 or more forms
-Hard copies or computerized form
-From information contained in the Health Record clinical management decisions and financial reimbursements are made
-It is essential to maintain a complete and accurate record

Question 3

Coding

Answer 3

-Prospective Payment System (PPS)
-Diagnostic Related Groups (DRGs)
-Conversion of diagnoses and procedures into a numerical classification system
-Conversion to these codes must be accurate
-Used for reimbursement from Medicare, Medicare and other insurance payors

Question 4

International Classification of Diseases –ICD -10-CM (effective October 1, 2015)

Answer 4

Used for procedural classifications.

Question 5

Health Record Content

Answer 5

-Patient Identification
-Medical history - chief complaint, present illness or injury, relevant family and social history, inventory of body systems
-Report of relevant physical exam
-Diagnostic and therapeutic orders
-Clinical observations, including results of therapy
-Reports of diagnostic and therapeutic procedures and tests as well as results
-Evidence of appropriate informed consent
-Conclusions at termination of hospitalization or evaluation of treatment, including any pertinent instructions for follow up care

Question 6

In Radiology

Answer 6

-Radiographers must be familiar with the format of the record and charting
-Need to review patient’s clinical history prior to performing the particular study

Question 7

Image Management

Answer 7

-Must maintain a secure electronic system for archiving of digital images
-For film, a computerized tracking system which may utilize bar coding

Question 8

Health Record in Radiology

Answer 8

-Must have a radiology order or request for service
-Must include patient demographic information
-Specific procedure requested
-Physician ordering

Question 9

Health Record in Radiology

Answer 9

-A diagnosis or sign or symptom must accompany each request
-If this isn’t documented there will be a delay or failure of payment
-If the procedure isn’t covered by the insurance the patient must be notified and is required to sign a form that states the patient will assume responsibility of payment

Question 10

Radiology Report

Answer 10

-Included in the patient’s record
-Describes the service that the patient receives
-Radiologist dictates the report and authenticates a description of what is seen and interpreted on the images
-A written report must be completed for every service rendered

Question 11

Legal Aspects of Health Records

Answer 11

-Legal Document
-Records what was done or what was not done to the patient
-Record may be submitted as evidence in court cases

Question 12

Not documented, 
Not Done!

Answer 12

-In the absence of documentation of what was done to the patient, it is assumed that an event did not take place.
-i.e. no documentation that pt’s reproductive organs were shielded

Question 13

Entries to the Medical Record

Answer 13

-If paper record, must be in ink
-Only approved abbreviations can be use
-Must be dated & timed
-Signature with printed name (may use stamper) and legal title
-EMR – date, time and signature are auto entered

Question 14

HIPPA

Answer 14

-As a healthcare provider you have access to the records of many patients.
-You should only access information that is necessary to care for your patients
-“Snooping” in other records could place your job in jeopardy!

Question 14

HIPPA

Answer 14

-Health Insurance Portability and Accountability Act
-Need to protect health information from inappropriate access or use
-Mandates both security and privacy of information

Question 14

Corrections/Amendments

Answer 14

-Author draws a single line through the error, write ERROR and then record the correct information
-The individual then dates and initials the correction
-Amendments (addendums) are added to the original record
-EMR – there is a process for corrections and amendments

Question 15

HIPPA

Answer 15

-EMR’s contain audit trails for every person accessing the record
-Facilities often run audits – often on the records of patients who are employees, or high profile figures in the community

Question 16

HIPPA

Answer 16

-Words to the Wise
-Never share your password
-Always log out of patients record
-Resist the temptation to snoop
-Properly dispose of any written material with patient medical information that is not part of the medical record – i.e. schedules

Question 17

Facsimiles/Emails

Answer 17

-Cover letter must include a confidentiality notice
-Emails must include a confidentiality notice

Question 18

Patient Access

Answer 18

-Because of federal laws, patients have the right to access their medical records
-Hospitals have the right to charge a fee to the patient for this record
-The hospital has a right to require a properly completed and signed authorization
-A hospital has the right to prohibit patient access when the provider reasonably believes that having access is not in the best interest if the patient’s health or that the knowledge may cause danger to the life or safety of any person.

Question 19

Patient Access

Answer 19

-A patient may ask to see their chart during transport or while waiting for their radiological procedure.
-This information should not be shared with the patient in this manner. The patient could misinterpret what is written or may not have been informed of the information.
-The technologist should refer the patient to the physician for discussion of the record.

Question 20

Mammography Records

Answer 20

-Mammography Quality Standards Act (MQSA)
-A facility must keep a mammogram in the permanent record of the patient for no less then 10 years
-A facility must also, on request, transfer mammograms to another facility, to another physician or to the patient directly.

Question 21

Health Record in Court

Answer 21

-The health record is a legal document that is admissible as evidence in court.
-A health information manager may be required to honor a subpoena for the record and take the record to court.
-The original record is never left in court. A photocopy is used.
-The copy is often sent by certified mail.