Health Records Flashcards
How many years should a patient’s record be kept?
Minimum of 7 years from the date of the completed treatment
How many years should a patient’s record be kept if the patient is a minor?
Minimum of 7 years from the date of the completed treatment and at least until they turn 19
How many years should the records of unemancipated minor be kept after the minor reached 18?
At least 1 year and not less than 7 years
If a person’s injury was a result of abandonment of health records what can happen?
An action may be brought to court
What should be given to the patient if they made a payment to the practice?
- Patient’s name
- Number of optometrist license
- Place of practice
- Description of the goods and amount charged
True/False A person has a right to possess complete info respecting his/her care and condition.
True
True/False A person who are in care of another has a right to access their condition/care
True
Who are the health care provider?
- Health care facility
- Clinic licensed
- Home health agency
- Physician and surgeon
- Podiatrist
- Dentist
- Psychologist
- Optometrist
- Chiropractor
- Marriage and family therapist
- Clinical social worker
- Physical therapist
- Occupational therapist
- Occupational therapist
- Professional clinical counselor
What is included in the mental health record?
Evaluation or treatment of mental disorder. Not limited to alcohol and drug abuse records
What is included in the patient records?
Health history, diagnosis or condition of the patient
But it does not include information given in confidence to the provider
Who are the patient’s representatives?
- Parent or guardian of a minor
- Guardian of a person of an adult patient
- An agent
- Beneficiary of a deceased patient
What is in the alcohol and drug abuse records?
Evaluation and treatment of alcoholism or drug abuse
How many business days should an optometrist provide the record after receiving the record request?
Within 5 working days
How many days should the copies of the record be transmitted after receiving the request?
Within 15 days
Can the patient or representative request the format of the record?
Yes, either electronic or paper
How many days should a request of imagining be sent when requested?
Within 15 days
The requested copy of a health record is to be provided without cost if the request is for which program?
- Medi-Cal
- In Home Supportive Services
- California Work Opportunity
- Responsibility to Kids
- Social security disability insurance benefits
- Supplemental Security Income/State Supplementary Program for the Aged, Blind, and Disabled benefits
- Federal veterans services connected compensation
- Nonservice connected pension disability benefits
- CalFresh
True/False Records can be requested multiple times, but only free of charge with 1 copy
True
If the patient was represented by a private attorney who is paying for the cost does this subdivision applies?
No
Can one charge the patient for the copies of the medical record if they successfully eligible for public benefit program?
Yes
How many days should the copies of the record be transmitted if the request is for public benefit program?
Within 30 days
Can a health care provider request deposit fee for the return of original x ray?
Yes
True/False is it a unprofessional conduct if the health care provider violates the chapter for health records?
True
What happens when one violates this chapter?
Infraction punishable by 100 dollar fine that may include suspension or revocation of the license
Can a provider withhold records due to unpaid bill?
No
What can happen if a provider without records due to unpaid bill?
Guilty of unprofessional conduct, fine of 100 dollars that may include suspension or revocation of the license
In which condition can the provider impose a reasonable fee for the records?
- Labor for copying record
- Supplies to create the record
- Postage for mailing the records
- Preparing an explanation or summary of the record
How much can the provider charge the patient for the records?
25 cents per page on paper or 50 cents per page on microfilm
If the provider opt for a summary of the record, within how many days should the summary be available?
10 working days
If the the provider needs an extension for providing the summary of the record due to extraordinary length of the record or the patient was just being discharged within the last 10 days, what should the provider do?
Notify the patient and the situation and within 30 days elapse between the request by the patient
Can the provider ask the patient in regards to requesting the record?
Yes
If the patient request info about only certain injuries, illnesses, or episodes should a provider required to prepare the summary?
No
What should the summary of the record include?
- Chief complaint
- Findings from consultation/referrals
- Diagnosis
- Treatment plan and regimen
- Progress of treatment
- Prognosis
- Pertinent reports of diagnostic procedures and tests and all discharge summaries
- Objective findings
- List of all current medication prescribed (dosage, any sensitivities or allergies to medications)
Should the cost of the summaries of records be made available at the lowest possible cost to the patient?
Yes
