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Medicine & Society 1 > Medical Informatics > Flashcards

Medical Informatics Flashcards

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1
Q

What is a medical record?

A

a document where all the subjective and objective findings regarding a patient is assimilated into one concise statement about the patient.

“legal document”

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2
Q

Who does the medical record belong to?

A

The patient
Have right to full access to the record

Institution or doctor are only custodian of the record

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3
Q

Information in the health record is protected by who?

A

HIPPA

Health Insurance Portability and Accountability Act 1996

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4
Q

What does HIPPA do?

A

protects and enhances the right of consumers by providing them with access to their health information and controlling inappropriate use of that information

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5
Q

What does the health record serve as?

A
  • A means of communication between the physician and other members of the healthcare team providing care to the patient
  • Basis for planning the care and treatment
  • A basis of evaluating the adequacy and appropriateness of patient care
  • Assists in protecting the legal interests of patients, healthcare professionals, and healthcare facilities
  • Means by which the patient and the insurance company can verify that services billed were actually provided
  • Clinical data for research and education.
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6
Q

In the health record, what should you do?

A
  • record all pertinent data
  • avoid irrelevant data
  • use common terms
  • Avoid abbreviations
  • be objective
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7
Q

What should the health record contain?

A 
Identification sheet 
Problem List 
Medication Record 
History and Physical 
Progress Notes 
Consultation 
Physician's Orders 
Imaging & X-ray reports 
Lab results 
Immunization Records 
Consent and Authorization forms 
Operative Report 
Pathology Report 
Discharge Summary
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8
Q

What is the identification sheet?

A

A form originated at the time of registration or admission. This form lists name, address, phone number, insurance and policy number

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9
Q

What is the problem list?

A

a list of significant illnesses and operations patient have or had

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10
Q

What is a medication record?

A

a list of medicines prescribed or given to the patient

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11
Q

What is the History and Physical part of the Health record?

A

A document that describes any major illnesses and surgeries patient have or had, any significant family history of diseases, health habits, and current medications. It also states what the physician found when a physical examination was done

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12
Q

What is the progress note?

A

Notes made by the doctors, nurses, therapists, and social workers caring for patient that reflect the response to treatment, their observations and plans for continued treatment

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13
Q

What is the consultation portion of the health record?

A

An opinion about the condition made by a physician other than the primary care physician.

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14
Q

What are physician’s orders?

A

Physician’s directions to other members of the healthcare team regarding medications, tests, diets, and treatments.

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15
Q

What is the Imaging and X-ray report?

A

Describe the findings of x-rays, mammograms, ultrasounds, and scans

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16
Q

What should the lab reports contain>

A

Describe the results of tests conducted of body fluids. Examples include a throat culture, urinalysis, cholesterol level and complete blood count etc

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17
Q

What is an immunization record?

A

A form documenting immunizations given for disease such as polio, measles, mumps, rubella, and the flu etc.

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18
Q

Copies of consent for admission, treatment, surgery and release of information

This describes what?

A

Consent and Authorization Form portion of Health Record

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19
Q

What is an operative report?

A

A document that describes surgery performed and gives the names of surgeon and assistants

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20
Q

What is a pathology report?

A

Describes tissues removed during an operation and the diagnosis based on examination of that tissue.

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21
Q

What is the discharge summary?

A

A concise summary of a hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet and follow-up care

22
Q

Who manages the health record?

A

trained health information management professionals maintain the health record.
They are responsible for ensuring that the health record is accurate, complete, confidential and available when you or your patient needs access to the information.

23
Q

How long is the health record is maintained?

A

for indefinite period of time or as specified in the state law. (in paper and electronic formats

24
Q

This requirement - that the health record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity among health care providers - is required by who?

A

Joint Commission on Accreditation of Healthcare organizations

Also req. that the health record data and information be managed in a timely manner

25
Q

What are basic empathy techniques?

A 
Types of Questions
Open ended questions
Direct Questions
Question types to be avoided
Silence
Facilitation
Confrontation
Interpretation
Reflective
Support
Reassurance
Empathy
26
Q

The history format includes?

A
  • Source and reliability
  • Chief Complaint
  • History of present illness
  • Past medical history
  • Occupational and environmental history
  • Family History
  • Psychosocial history
  • Review of systems
27
Q

The history and physical should include?

A

chief complaint, details of present illness, relevant past, social and family histories, inventory of body systems, medications (with doses) and allergies.

Should include a comprehensive current physical assessment. A statement of the conclusions or impressions drawn, statement on the course of action planned, admission labs and x-rays should be noted

28
Q

When should the history and physical be concluded?

A

If patients are hospitalized the history and physical examination must be completed within 24 hours of inpatient admission and prior to surgery and other procedures, such as cardiac catheterization.

29
Q

If a member of the medical staff has performed a complete physical exam within 90 days prior to admission can a copy of the report be used for the current visit?

A

No,

Has to be within 30 day

30
Q

The result of integrating the patients history and physical examination with statistics and epidemiology should lead to?

A

Clinical decision making

“Medicine is the source of uncertainty and an art of probability. One of the chief reasons for this uncertainty is the increasing variability in the manifestation of any one disease.”

31
Q

What are the primary steps for clinical decision making?

A

Data Collection
Data processing
Problem development

32
Q

What does SOAP stand for?

A

Subjective
Objective
Assessment
Plan

33
Q

Diagnostic and Therapeutic falls under which part of a SOAP note?

A

Plan

34
Q

How should health record be recorded?

A
  • Diagnosis must be recorded in full, without the use of symbols or abbreviations, signed and dated by the responsible practitioner at the time of patient encounter.
  • Accurate dating, signed, and timed for clinical entries
  • legible entries and signature (printed name with signature is recommended)
35
Q

How do you ament or correct an entry in the medical record?

A

draw a single thin line through each line of the inaccurate material, making certain it is still legible, date and initial the error, enter the correction, and record the date and time the correction was made

36
Q

What is a medical necessity?

A

A service that is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of the individual

37
Q

What is the criteria for medical necessity?

A

Service must be consistent with the symptoms or diagnoses or illness or injury under treatment; must be necessary and consistent with generally accepted professional medical standards (i.e., not experimental or investigational); the patient’s presenting problem should drive the extent of the service performed.

38
Q

What is the benefit to have electronic health records?

A
  • Better health care
  • reducing treatment errors
  • ease of access and storage
39
Q

What is an Electronic Health Record (EHR)?

A

computerized system where patient records are created, used, exchanged, stored and retrieved

40
Q

What is the goal of Electronic Health Records?

A

replace the paper with an electronic record while maintaining all of the elements of the traditional paper-based method, including all of the information about a patient’s care throughout the lifetime of the patient

41
Q

What are the pros to using Electronic Health Record?

A

Patient care improves
Risk reduced
HIPAA compliance is ensured
reduction expenses and increase revenue without working longer hours

42
Q

How does Electronic health records improve patient care?

A
  • Provide your patients with prescription recalls, alerts and warnings – at their appointment, or by e-mail or via telephone.
  • Speed-up patient appointments by having all of their information at your fingertips.
  • Prevent prescription dosage and handwriting recognition errors.
  • Prevent medication conflicts with allergies, other meds, medical conditions and family history
  • easy and quick sending of prescription
  • improve diagnosis and educate patients (Access integrated evidence-based consultation support for patient evaluation, diagnosis and management built right into the system)
  • improve quality and clarity of your documentation, reducing the risk of frustrating transcription error, costly misdiagnosis and dangerous drug interactions
43
Q

how does electronic health records simplify practice?

A
  • easy access from any device with internet access, chart 2on the go (elimination of cost and time)
  • eliminate the need for manual records transcription (easy manage of office with fewer staff, time saved)
  • easily provide comprehensive documentation for referral (provide to other physicians)
  • eliminate errors in real-time so only error-free claims are submitted. Get paid faster, with less back and forth paperwork
  • reduce data analysis cost - has extensive reporting capabilities so you can track progress easily
44
Q

How does electronic health records boost your revenues?

A
  • streamline patient flow

- get paid for the service you provide.

45
Q

SLide 38

A

Slide 38

46
Q

Slide 39

A

Slide 39

47
Q

What is HIPPA

A

The Health Insurance Portability & Accountability Act of 1996 (August 21), Public Law 104-191, which amends the Internal Revenue Service Code of 1986. Also known as the Kennedy-Kassenbaum Act.

48
Q

What does HIPAA require?

A
  1. Improved efficiency in health care delivery by standardizing electronic data interchange, and
  2. Protection of confidential and security of health data though setting and enforcing standards.
49
Q

Who uses HIPAA?

A 
Healthcare Information Exchange 
Hospitals 
EMR 
Medical Supplication Providers 
Physicians/Medical Staff
Pharmacies 
Health Plans 
Device Manufactures 
Employers 
Laboratories
50
Q

What does HIPAA more specifically call for?

A
  1. Standardization of electronic patient health, administrative and financial data
  2. Unique health identifiers for individuals, employers, health plans and health care providers
  3. Security standards protecting the confidentiality and integrity of “individually identifiable health information,” past, present, and future.
51
Q

Who is affected by HIPAA?

A

All healthcare organizations. This includes all health care providers, even 1-physician offices, health plans, employers, public health authorities, life insurers, billing agencies, information systems vendors, services organizations, and universities.

52
Q

Are there penalties with HIPAA?

A

HIPAA calls for severe and criminal penalties for noncompliance, including-fines up to $25K for multiple violations of the same standard in a calendar year-fines up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information.

Medicine & Society 1 (10 decks)

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