chapter 23 Health Records

Question 1

who maintains health records

Answer 1

hospitals, ambulatory care facilities, ER and trauma centers, long term facilities, rehab facilities, home care programs, physician practices

Question 2

promotes effective communication among health care professionals
continuity and quality of care
ensure complete documentation

Answer 2

why health records and health info. management

Question 3

hard copy
microfilm
computerized

Answer 3

forms

Question 4

care of patients
institutions admin process
patient billing and accounting
medical education programs
research
utilization management
risk management
quality assurance program
HIPPA
legal requirements
follow up care

Answer 4

function of health records department

Question 5

wrong exam done

allergic reaction

Answer 5

error in medicine

Question 6

misdiagnosis

loss of revenue

Answer 6

error in data reporting

Question 7

standards of health records are set by who

Answer 7

TJC (the joint commission)

HFAP(healthcare facilities accreditation program)

Question 8

who is CMS

Answer 8

center for medicare and medicaid services. they authorize TJC/HFAP to survey medical facilities

Question 9

if patient care involved must document in record (also known as charting)

Answer 9

health record content

Question 10

when patient receives diagnostic procedure, contrast, reactions, clinical date, patient history

Answer 10

radiology dept when to chart

Question 11

radiology information system(history, exam)

hospital information system(insurance, employment)

Answer 11

RIS, HIS

Question 12

electronic health records
TJC establishes standards
facilities can have their own program

Answer 12

EHR

Question 13

patient ID
medical history
diagnostic orders
reports

Answer 13

included in EHR

Question 14

informed consent
consent for treatment
incident report (state facts not opinions)
administration keeps incident reports for legal purpose but it is not included in patients records

Answer 14

health record content

Question 15

an order or request form to perform procedure
clinical date, history
if medicare does not cover must tell patient(advances beneficiary)
patient report
authentication signature by radiologist
stored in film, file, RIS or PACS and in patients file

Answer 15

health records in radiology

Question 16

dated
date of exam
date of radiologists signature
authenticated by signature of radiologist
in ink
line thru error, write error, date and sign
“not documented, not done”

Answer 16

requirements of entries

Question 17

coding of patients
diagnosis and procedures converted to numeric classification
complete and accurate

Answer 17

reimbursement requirements

Question 18

System for Medicare patients
Federal govt enacted 1983
Hospitals are paid a predetermined rate according to DRG
CMS under HHS controls it

Answer 18

PPS Prospective Payment System

Question 19

Determines standard care rate for a group

Answer 19

DRG diagnostically related group

Question 20

Reimbursement in outpatient setting

Answer 20

APC ambulatory patient classification

Question 21

Numerical coding system to indicate patients DRG diagnostically related group
Revision October 2015

Answer 21

ICD 10 CM

Question 22

Codes used for outpatient radiology and labs

Answer 22

CPT current procedural terminology

Question 23

Must be accurate to receive payment or deny
Ranges from 70010 to 79999
Example is cervical spine with contrast 72142

Answer 23

Reimbursement coding

Question 24

Used for coding specimens

Answer 24

IRD index of radiologic diagnosis

Question 25

May be used in court You may be called upon for testimony or deposition Incorrect billing is fraud must follow regulations

Answer 25

Legal aspects of health records

Question 26

``` Must be author of mistake Line out Write error Date, sign Can be amended by patient but original still exists EHR more difficult to fix ```

Answer 26

Health records correcting or amending

Question 27

sign statement as student or employer Refer them to physician with results Privileged communication in some states

Answer 27

Confidentiality of health records

Question 28

Must be in writing Who is receiving info Patient name, address, date of birth, date, signature, extent of info May be charged for copies

Answer 28

Consent to release

Question 29

Used if time is a factor Required for 3rd party payer Include confidentiality notice

Answer 29

Sending health records as a fax

Question 30

``` Policy against sharing passwords, access codes, key cards Password 7 characters Change frequently Access only info you need Lock out if improper code Access to records is tracked ```

Answer 30

Health records information security

Question 31

``` Have right to access Can be charged for copies Hospitals ask for patient authorization Hospitals can hold back release Don't share images with patient ```

Answer 31

Patient access to health records

Question 32

Record kept for 5 years | 10 years if no previous record

Answer 32

MQSA mammography quality standards act

Question 33

Enacted by congress in 1996 Protects inappropriate access Department of health and human services enforces it Can be charged civil or criminally if not followed Health care providers and health plans must follow

Answer 33

HIPPA health insurance portability and accountability act

Question 34

Any information that can identify a patient. If info not related to treatment must get patient authorization

Answer 34

PHI protective health information

Question 35

Can we share PHI?

Answer 35

Yes when part of our job

Question 36

Record of who received patients info, for what purpose, when released

Answer 36

Accounting of disclosure

Question 37

Determines who may be given info and who may not

Answer 37

TPO treatment, payment, operational needs

Question 38

Must have security software Encryption of data Firewalls

Answer 38

PHI in portable devices

Question 39

Give name and room number only

Answer 39

If asked over phone about patient

Question 40

Disposing of patient info

Answer 40

Shred

Question 41

Form patient signs giving permission for their PHI to be released, who is receiving and what purpose

Answer 41

Authorization form

Question 42

If you inadvertently over hear or see info about patient that you don't need to know is termed

Answer 42

Incidental disclosure

Question 43

``` Access EHR not involved with patient Stolen laptop/lost, unsecured PHI Posting patient info on social media EOB explanation of benefits sent to wrong guarantor Access own EMR Take pics of injuries Non work related access ```

Answer 43

Breaches of HIPPA

Question 44

``` Can get access to insurance info Confidential info remains confidential Sign new HIPPA form In charge of own medical record Parent listed as having access Parent is advisor ```

Answer 44

At age 18

Question 45

Check that policies are followed Check computers Check encryption

Answer 45

Periodic audits

Question 46

Allows judgement call and experience to decide if info can be released if in patients best interest Can use sign in and call out Images not violation if anonymous

Answer 46

HIPPA allows

Question 47

Protects privacy of student education records Rights to students Transfer at age 18 Can inspect, review, have school correct

Answer 47

FERPA family educational rights and privacy act