Unit 1 Flashcards
Medical Record
- contains info on treatment by healthcare provider
- legal doc
- used for treatment/billing purposes
EHR
• computerized lifelong healthcare record for a patient
- contains data from all sources to provide treatment
- maintained by multiple providers/ facilities
EMR
• electronic medical record
- maintained by 1 provider
PHR
personal medical record
-maintained by patient
Why transition to EHR
• medical errors:
- handwriting, medication/surgical
• communication problems:
- misfiled, duplicate tests, coordination of care
HIPAA
- federal law that governs the use, transfer and disclosure of identifiable health info
- passed because patient care info was being used in ways that violated their privacy
PHI ( protected health info)
•individually identifiable health info
•protects info in any form
- paper, electronic, spoken, dead/living, recorded
Covered Entity
any organization that directly handles PHI
notices of privacy practices
- given on 1st encounter with health agency and at least once every 3 years after (or change in practice)
- describes patients rights under HIPAA
HIPPA principles
governed by 2 main practices:
> need-to-know :
- what info do you need to know to do your job
> minimum necessary:
- are you using or disclosing the smallest amount of PHI necessary to complete the job
de- identifying information
• anything that could be used to identify patient must be removed from any shared documentation
> expectations = public health , law enforcement, natural security situations
what is used to identify a patient ?
- name
- geographic
- all elements of date (expect year)
- phone/ fax numbers
- email address
- numbers (social security)
- full face photographs/complete type
disposing PHI
-secure way
>documents = shredded/incinerated
> not be placed trash cans/recycling
> hard drives wiped clear
examples of HIPAA violations
- accessing health info of coworkers, family, celebs
- telling patient info
- sending PHI over emails
patients rights under HIPAA
-right to request alternative communications ( voicemail)
- right to ask for changes for
medical/billing records
non-compliance with HIPAA
- fines= up to $50,000 for each violation per year
* individual criminal penalties=up to 15 million dollars + prison for 10 years
health info and data
-demographic info
-clinical info
> procedures
> diagnosis
> allergies
> diagnostics test results
> treatment plan
results management
access to current/past test
results performed by anyone involved in treatment of patient
order management
able to send,receive and store orders for medications,tests, and other services by any provider involved in treatment
decision support
- computer based access to lasted clinical research
* computer based access to latest info on medication
electronic communications
•provides easy access to emails for healthcare provider
- provider-provider - team coordination - patient-provider - external partners ( insurance)
patient support
- offers patients access to appropriate educational materials
- offers patient ability to report to their physicians on home monitoring/testing
administrative process
- scheduling management (appointments)
- Eligibility determination (insurances)
- medical coding
Reporting / Population Management
• assists in detecting threats to health of the general population
• Epidemics
- Bioterrorism
24 hour clock (military time)
- used to prevent confusion
- numbers 1-24 instead of 1-12
- last 2 numbers = minutes
- always 4 digits without colon
Progress Notes
written statement about a patients care
- each medical facility implements certain type of progress notes
SOAP notes
format for charting • Subjective • Objective • Assessment • Plan
Subjective
Info obtained from what the client says
- clients family perception
- cannot be observed by healthcare provider
- use quotes
Objective
• info that’s measured/observed
ex= vital signs
• no opinion
•measurable
Assessment
- interpretation/conclusions drawn about the subjective and objective data
- should describe clients condition/progress
Plan
The plan of care designed to resolve stated problem
Effective Communication
• shared meaning and understanding between 2 people
- communicator must consider their audience
•requires listening,speaking, reading,observing, writing skills
Listening skills
- face sender
- eye contact
- attention on speaker
- ask for clarification
- don’t interrupt
- be comfortable with periods of silence
Speaking skills
- speak clearly and distinctly
- speak to listen
- choose words that audience will understand
- talk “with” your listener and not “at” them
Reading skills
- vocabulary
- progress notes,graphs,manual and research
Observations skills
- looking for messages that aren’t spoken
- nonverbal messages
- be mindful of your facial expressions
Writing skills
- clear
- concise
- accurate
