Lecture #6 (Information Management) Flashcards
What is a cumulative outline of a patient’s health history and treatment done by the AT and/or sports medicine team?
Medical records
How long do medical records need to be stored?
10 years
What is a system of medical record keeping that organizes information around a patient’s specific compliants?
Problem-orientated medical record (POMR)
What type of charting involves a medical record that registers a patient’s complaint data, the health care practitioner’s actions, and the patient’s response? Who would use this?
Focus charting; ATs
What type of charting involves a method of recording the patient’s assessments and treatments using a detailed lengthy narrative format? Who would use this?
Narrative charting; doctors
What type of form is used for athletes to take with them when seeing another medical professional? Why is this necessary?
Referral form; it proves a referral was made and allows space for the medical professional to relay information back to the AT (especially because athletes can be unreliable)
What should the emergency medical form include?
- name, address, phone number(s), DOB, SS# or student ID#
- parent(s) or guardian(s)
- insurance information
- any special instructions for treatment
What is a signed release from a patient or parent that waives all future legal claims against a practitioner and/or their employer?
Exculpatory clause
What does FERPA stand for?
Family Educational Rights and Privacy Act
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
True or false: Under FERPA, the third party cannot get medical information about the student without their authorizaton.
True…FERPA also covers medical information in this case
True or false: Insurance information is considered part of a medical record.
False
