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HIS-Lec > U1.3-1.4: Primary Health Care and Legal Aspects > Flashcards

U1.3-1.4: Primary Health Care and Legal Aspects Flashcards

1
Q

an essential health care made universally acceptable to individuals and families in the community (WHO)

A

primary health care

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2
Q

What type of approach does primary health care use?

A

societal approach; not individual
(centered on the needs and preferences of families)

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3
Q

T/F: Health management is for the improvement of a selected group.

A

False
for the whole population

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4
Q

3 parts of the pyramidal health structure

A

Top to bottom:
Tertiary health care
Secondary health care
Primary health care

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5
Q

Services included in the tertiary health care (pyramidal health care)

A

National health services

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6
Q

Services included in the secondary health care (pyramidal health care)

A
  1. Regional health services
  2. District health services
  3. Rural (local hospital) services
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7
Q

Services included in the primary health care (pyramidal health care)

A
  1. Rural health units
  2. Barangay health stations
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8
Q

Two Types of Primary Health Care Workers in the Philippines

A
  1. Barangay Health Workers (BHW)
  2. Intermediate level primary health worker
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9
Q

4 Pillars of Primary Health Care

A
  1. Community participation
  2. Intersectoral coordination
  3. Appropriate technology
  4. Support mechanism made available
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10
Q

8 Elements of Primary Health Care

A
  1. education
  2. water and sanitation
  3. nutrition
  4. maternal and child health
  5. immunization
  6. prevention of endemic disease
  7. treatment
  8. drug availability
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11
Q

governed by multiple state and federal laws and regulations in addition to those for licensure and certification

A

Health care information (patient-specific information)

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12
Q

signature on a document

A

Authentication

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13
Q

involves burning or shredding

A

Destruction of records

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14
Q

In addressing the medical record as a legal document, what are the factors to consider?

A
  1. the issues of retention
  2. authentication of health care information
  3. the privacy and confidentiality of patient information
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15
Q

association that declared the “Guidelines for Defining the Health Record for Legal Purposes”

A

American Health Information Management Association (AHIMA)

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16
Q

What does AHIMA stand for?

A

American Health Information Management Association

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17
Q

association that defined the legal health record (LHR) as the documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization

A

American Health Information Management Association (AHIMA)

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18
Q

What does LHR stand for?

A

legal health record

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19
Q

documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization

A

Legal Health Record (LHR)

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20
Q

includes records of care in any health-related setting used by healthcare professionals while providing patient care services, for reviewing patient data, or documenting observations, actions, or instructions

A

Legal Health Record (LHR)

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21
Q

exclusions of LHR

A
  1. health records that are not official business records of a healthcare provider organization
  2. records such as personal health records (PHRs) that are patient controlled, managed, and populated
22
Q

data from which interpretations, summaries, notes, etc., are derived

A

Patient-identifiable source data

23
Q

patient-identifiable data used for administrative, regulatory, healthcare operations, and payment (financial) purposes.

A

Administrative data

24
Q

consists of information aggregated or summarized from patient records so that there are no means to identify patients

A

Derived data

25
Q

Identify if documentation found in LHR, patient-identifiable source data, administrative data, or derived data:

  • advance directives
  • anesthesia records
  • care plan
  • consent for treatment forms
  • consultation reports
  • discharge instructions
  • discharge summary
  • e-mail containing patient-provider or provider-provider
    communication
A

documentation found in LHR

26
Q

Identify if documentation found in LHR, patient-identifiable source data, administrative data, or derived data:

  • authorization forms for release of information
  • birth and death certificates
  • correspondence concerning requests for records
  • event history/audit trails
  • patient-identifiable claim
A

administrative data

27
Q

Identify if documentation found in LHR, patient-identifiable source data, administrative data, or derived data:

  • analog and digital patient photographs for identification purposes only
  • audio of dictation
  • audio of patient telephone call
  • diagnostic films and other diagnostic images from which interpretations are derived
  • electrocardiogram tracings from which interpretations are derived
  • fetal monitoring strips from which interpretations are derived
  • videos of office visits
  • videos of procedure
  • videos of telemedicine consultations
A

patient-identifiable source data

28
Q

Identify if documentation found in LHR, patient-identifiable source data, administrative data, or derived data:

  • accreditation reports
  • anonymous patient data for research purposes
  • best practice guidelines created from aggregate patient data
  • Minimum Data Set (MDS) report
  • public health records
  • statistical reports
A

derived data

29
Q

T/F:
Majority of states have specific retention requirements for health care information.

A

True

30
Q

The state retention requirements should be the basis for the health care organization’s _________ __________ ___________.

A

formal retention policy

31
Q

T/F:
When no specific retention requirement is made by the state, all patient information that is a part of the LHR should be maintained for 5 years.

A

False;
maintained for at least as long as the state’s statute of limitations or other regulation requires

32
Q

Identify the association:
“recommended retention standards”

A

AHIMA

33
Q

AHIMA states that patient health records for adults should be retained for _____ years after the most recent encounter and patient health records for children should be retained until the time the person reaches the _____ ___ _________ plus the time stated in the relevant statute of limitations.

A

ten
age of majority

34
Q

In AHIMA’s destruction guidelines, why should the records be destroyed?

A

so there is no possibility of reconstruction

35
Q

Ways to destroy records (AHIMA)

A
  1. Burn, shred, pulp, or pulverize paper.
  2. Recycle or pulverize microfilm or microfiche.
  3. Pulverize write-once read-many laser disks.
  4. Degauss computerized data
36
Q

According to AHIMA’s destruction guidelines, what should be documented upon destruction?

A
  1. Date of destruction.
  2. Method of destruction.
  3. Description of destroyed records.
  4. Inclusive dates of destroyed records.
  5. A statement that the records were destroyed in the normal course of business.
  6. Signatures of individuals supervising and witnessing the destruction
37
Q

T/F:
Maintain the destruction documentation indefinitely.

A

True

38
Q

“The validation of correctness for both the information itself and for the person who is the author or the user of the information”

A

authentication
(defined by Joint Commission Hospital Accreditation Manual)

39
Q

created when the provider enters a unique code, biometric, or password that verifies his or her identity

A

Electronic signature

40
Q

Electronic signatures show up on the computer screen or printout in what form?

A

“Electronically authenticated by____________”

41
Q

T/F: Electronic signatures are accepted by The Joint Commission ONLY.

A

False
accepted by both The Joint Commission and CMS

42
Q

What types of records cannot be destroyed?

A
  1. histopath data
  2. birth records
  3. death records
43
Q

an individual’s constitutional right to be left alone, to be free from unwarranted publicity, and to conduct his or her life without it being made public

A

privacy

44
Q

individual’s right to limit access to his or her health care information.

A

privacy

45
Q

the expectation that information shared with a health care provider during the course of treatment will be used only for its intended purpose and not disclosed otherwise

A

confidentiality

46
Q

Confidentiality relies on _______.

A

trust

47
Q

Philippine AIDS Prevention and Control Act of 1998

A

RA 8504

48
Q

RA 8504

A

Philippine AIDS Prevention and Control Act of 1998

49
Q

RA 8504 approval date

A

Feb. 13, 1998

50
Q

According to RA 8504, all results of HIV/AIDS testing shall be __________.

A

confidential
(Codes are used instead of names)

51
Q

According to RA 8504, the test result shall be released only to?

A
  1. person who submitted himself/herself to such test
  2. parent of a minor child who has been tested
  3. legal guardian in case of insane persons or orphans
  4. person authorized to receive such results in conjunction with the AIDSWATCH program
  5. Justice of the Court of Appeals or the Supreme Court

HIS-Lec (6 decks)

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