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Flashcards in Chapter 1 Deck (49):
1

Discuss why protecting the privacy and confidentiality of health information is a challenge.

Health information is more easily accessible than ever before

2

Describe primary and secondary uses of health information

Primary-clinical care, secondary-public health reporting, public safety, population health studies, third party reimbursement, and patient safety

3

Discuss the difference b/n a paper health record, a hybrid record, and an electric record

Paper- all files are printed, hybrid is a mix of electronic and paper, and electronic is all on computer or system

4

Define privacy

The right to be left alone

5

Define confidentiality

Protecting private thoughts shared with one another

6

Define security

Physical protection of information that preserves confidentiality

7

Explain the theoretical concepts behind privacy, confidentiality, and security

Private information is the most sensitive and can affect the patient if leaked

8

Discuss ownership and control of the health record.

Traditionally owned by physician, however the individual has rights to view or prohibit

9

Discuss the role and responsibilities of the custodian of health records

They are responsible for care, control, safekeeping, disclosure, evidence for legal cases, may be called to testify, inspection, and duplication of records.

10

Who may serve as the custodian of health records?

The director of the him dept traditionally, or another individual who can verify

11

Describe the role of professional codes of ethics in protecting health information

They provide a framework and set of standards for protecting health information.

12

AHIMA

American health information management association-provides accreditation, advocacy, certification, and education to health information technologists and managers including coding services

13

AMA

American medical association-association of physicians that distributes scientific information, represents in legal proceedings, and advises legal issues

14

AMIA

American medical informatics association-association of health informatics and health information management personnel, biomedical informatics professionals, and educators.

15

ARRA

American recovery and reinvestment act of 2009-federal legislation that funded HIT and changes to HIPAA privacy rule

16

ASTM

American society for testing and materials-organization dedicated to creating standards for materials, products, systems and services

17

Autonomy

Individual's right to self determination, in charge of what happens to him, or information

18

Business record

A record kept for normal business

19

Code of ethics/code of ethical practice

Reflects the values and principles defined by a professional setting as acceptable behavior

20

Designated record set

A defined group of information that may consist of medical and billing records, information about payments, case management systems, and other information used to make health care decisions.

21

Electronic health record

An electronic record that can be utilized by more than one organization.

22

Electronic medical record

Electronic record used by only one healthcare organization.

23

Ethics

Standards of behavior regarding right and wrong.

24

Ethical principles

Set of four principles for healthcare professionals - autonomy, beneficence, nonmaleficence, and justice.

25

Health information

Data generated and collected as a result of caring for a patient

26

Health information exchange

Electronic movement of health information, or an entity that forms to create links between physicians to pharmacies, hospitals, and other health entities

27

Health information technology

The technical aspects of processing health data and records, including coding,abstracting, registry devmt, and storage

28

HITECH

Health information technology for economic and clinical health act

29

HIPAA

Health insurance portability and accountability act of 1996

30

Health record

Individually identifiable data that documents the care of an individual.

31

Information governance

Management of electronic information including standards for access, use, and control of the information.

32

The joint commission

Agency that develops standards for healthcare organizations and certifies them based on their adherence to those standards

33

Law

A set of governing rules used to protect the public.

34

Legal health record

LHR- the record that is the legal business record that serves as evidence in legal actions

35

Moral values

Principles formed through family, culture, religion, and society

36

NAHIT

National alliance for health information technology-2002-2009, formed to improve safety, quality of care, and operating performance through the use of technology

37

Nonmaleficence

Legal principle of first do no harm

38

ONC

Office of the national coordinator for health info technology-2004, created by fed govt to create health information technology to improve the quality and efficiency of healthcare

39

Personal health record

Electronic or paper record managed by the individual patient

40

Privileged communication

Communication between two parties such as a doctor and patient, or husband and wife that is considered privileged by law.

41

Steward

Person responsible for integrity and security

42

Stewardship

Responsibility for integrity (accuracy, completeness, timeliness) and security

43

System security

Protection of the hardware, software, access, prevention of misuse, protection of privacy

44

Ownership of a health record generated by a doctor belongs to whom?

Generally considered dr property, but patient has rights to it

45

What is the role of the custodian of records?

He or she is responsible for the care, custody, control, proper safekeeping, legal proceedings, and verify the record is what it purports to be

46

Autonomy

Recognizing the pt right to make their own choices

47

Beneficence

Doing good, promoting health and welfare, kindness, compassion, helping others

48

Nonmaleficence

Doing no harm

49

Justice

Obligation to be fair in the distribution of benefits and risks