APPROACH TO PATIENT INTERVIEW Flashcards
what does HIPAA stand for?
Health Insurance Portability and Accountability Act - 1996
what entity developed HIPAA?
Department of Health and Human Services
HIPAA: designed to 1)__________________ to 2)___________________________ and other health information provided to 3)_______ _________, 4)___________, 5)___________, and other healthcare providers
1) provide privacy standards to 2)protect patients’ medical records
3) health plans, 4) doctors, 5) hospitals
definition: provides patents with access to their medical records and more control over how their personal health information is used and disclosed
HIPAA
definition: the covered entity or business associate did not know an reasonably should not have known of the violation
unknowing (1st tier of culpability)
definition: the covered entity or business associate knew, or by exercising reasonable diligence would have known, that the act or omission was a violation, but the covered entity or business associated failed to act with willful neglect
reasonable cause (neglectful) (2nd tier of culpability)
definition: conscious, intentional failure or reckless indifference to fulfill the obligation to comply with HIPAA. However, the covered entity or business associate corrected the violation within 30 days of the discovery that resulted in a violation
willful neglect – corrected (knowing but not willful) (3rd tier of culpability)
definition: conscious, intentional failure or reckless indifference to fulfill the obligation to comply with HIPAA., and the covered entity or business associate did not correct the violation within 30 days of the discovery that resulted in a violation
willful neglect – uncorrected (willful and brazen) (4th tier of culpability)
when finding a case that you want to present for your class or any other presentation in the future… (2 steps)
1) talk to preceptor, go through appropriate channels: every rotation site is different on how you must obtain this information
2) copy what you need (i.e. pre-op note, anesthesia record, etc) and blackout deny identifying information
what does JCAHO stand for?
the Joint Commission on Accreditation of Healthcare Organizations
definition: a non-profit organization that accredits more than 20,500 healthcare programs and services in the US
JCAHO
what are the JCAHO accreditation cycles for health care organizations vs. laboratories?
health care organization: 3yr accreditation cycle
laboratories: 2yr accreditation cycle
which organizations are awarded the decision of Accreditation by JCAHO?
organizations deemed to be in compliance with all or most of the applicable standards
what does “unannounced” mean in terms of JCAHO?
“unannounced” means the organization does not receive an advance notice of its survey date
the following are components of what?
identification sheet, admission h&p, consent forms, medication summary, nurses assessments, consultation notes, physician’s progress notes, physician’s order sheets, lab reports, radiology reports, op/procedure/anesthesia record, discharge summary
the patient chart
definition: includes demographic information (name, DOB, address, SSN), employment, insurance, responsible party/emergency contact
identification sheet
how often should identification sheets be updated?
every year
definition: includes date & time, identifying data, chief complaint, history of present illness incl. meds, allergies, habits, past history, family history, personal/social history, review of symptoms (ROS)
H&P: history
which vital signs are included in the H&P?
blood pressure, heart rate, respiratory rate, temperature, and O2 saturation
definition: includes skin, HEENT, thorax/lungs, breasts/axillae, musculoskeletal, cardiovascular, abdomen, peripheral vascular/nervous system & genital/rectal exam
H&P: exam of all systems (physical exam)
definition: components include: patient name & date, name and description of surgery, indication for surgery, risks and benefits of procedure, alternatives to procedure, patient’s signature, printed name, date, and time/surgeon’s signature
consent forms
what critical component of the consent form can delay surgery?
patient must be competent to make medical decisions
what are the two components of the medication summary?
1) list of patient’s current medications while in the hospital
2) dosage, route, frequency, and whether patient has received the dose at a particular time
definition: components include: history (health status, course of present illness, current management, patient’s reception of illness), psychological and social exam, physical exam (signs that can be measured like vital signs and exam itself), assessment tools (activities of daily living, glasgow coma scale, and pain scales (fifth vital sign – ex. rate pain 1-10))
nursing assessment
