+
Related Flashcards
Related Topics
Cards In This Set
| Front | Back |
|
De-Identify Patient Public Health Information
|
Remove: Name, Telephone number, email, and DOB (but can leave the year)
|
|
Minimum Necessary
|
That which is required to do your job / when asked for records, only provide info necessary to do your job
|
|
National Databank HIPDB
|
Collects reports and disclosures for actions taken against healthcare practitioners for non-compliance and fraudulent activities
|
|
HIPAA (Health Insurance Portability and Accountability Act)
|
Protects personal information, prescribes rights to access of your medical information; Rules relating to research must include a wavier from the instructional review board
|
|
Medical Records should be retained for
|
7-10 years
|
|
Privacy Officer
|
Someone that makes sure our patient privacy policies and procedures are in place
Stay up on current laws for privacy also leads out on education of policies/procedures among staff, makes sure employees are trained properly |
|
Telemedicine
|
Technology driven
|
|
What type of organization/people would require a patient's health information that we would be allowed to disclose to?
|
Clergy, Police/Fire Dept/Rescue (Emergency Situation)
|
|
Medical Record
|
A record from your birth to your death/ legal document- can be subpoenaed
|
|
2 different types of documentation:
|
POMR & SOAP
|
|
POMR
|
Problem-Oriented Medical Record includes chronological record of each visit
|
|
SOAP
|
Subjective Objective Assessment Plan
S-subjective statement of patientO-objective data such as lab reports, vital signsA- assessment or diagnosisP-plan of treatment |
|
Under what condition can a patient's medical record be released?
|
Written permission
Patients who receive treatment for drug/etoh abuse- hihgly protected under the Public Health Services Act, can be released in an emergency |
|
What should you do if patient's medical record is subpoenaed?
|
Notify Patient and Physician, but NEVER violate not providing subpoena information
|
|
Who owns the patient's medical records?
|
The hospital facility- but patient has rights under privileged communication
|
