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Intro to Radiography > Chapter 25 > Flashcards

Chapter 25 Flashcards

1
Q

Who maintains health records?

A

Hospitals
Ambulatory Care Facilities
Emergency & Trauma Centers
Nursing Homes
Rehab Facilities
Home care programs
Physcian Practices

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2
Q

What is the purpose of HIM and Technology?

A

Continuity and quality of care provided for the patient

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3
Q

What forms are used for HIM?

A

Hard copy
Microfilm
Computerized

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4
Q

The health records department functions to support:

A

Care of patients
Administrative process
Billing & Accounting
Medical Education programs
Research
Utilization Mngmt
Risk Mngmt
Quality Assurance programs
HIPAA
Legal requirements
Extraneous patient serivces

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5
Q

What can happen if there is an error in medicine?

A

Wrong exam
Allergic reaction

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6
Q

What can happen if there is a data reporting error?

A

Misdiagnosis
Loss of revenue

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7
Q

Who sets the standards for health records?

A

TCJ - The Joint Commission
HFAP - Healthcare facilities Accredidation program

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8
Q

Who is CMS and what is their purpose?

A

Center for Medicare and Medicaid Services

Oversee and authorize TJC and HFAP to survey medical facilities

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9
Q

What is charting?

A

Documenting patient care in health record

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10
Q

When do radiologists chart?

A

When patient received diagnostic procedure

When contrast is involved

Clinical data and patient history

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11
Q

What is the RIS?

A

Radiologic Information System (patient history, exam, etc)

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12
Q

What is HIS?

A

Hospital Information System (insurance, employment, etc)

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13
Q

What is EHR?

A

Electronic Health Record

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14
Q

Health record must include what for procedures requiring consent?

A

Informed consent form

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15
Q

Does consent for treatement upon admission to the hosptial cover consent for specific procedures?

A

No

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16
Q

What are incident reports?

A

Administrative document completed after an incident - legal or RM

Known facts only

Report is not part of the patient’s record, but event is still documented in chart

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17
Q

What form is required to perform a procedure?

A

Order form or request form

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18
Q

What is ABN?

A

Advanced Beneficiary Notice - lets patient know that Medicare may not cover procedure and they are responsible for it. They sign it.

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19
Q

What type of report must be created for each radiologic procedure?

A

Patient report - radiologist must sign each report

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20
Q

Where are reports stored?

A

Film file (RIS) and in patient’s permanent record

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21
Q

All patient records must be:

A

Dated and authenticated

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22
Q

How to correct an error?

A

Single line through it
Write “error” and correct term
Date and sign it

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23
Q

What is the basic principle of patient record?

A

If it’s not documented, it’s not done

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24
Q

What is patient coding?

A

Coverting diagnosis and procedures into a numeric classification system

25
What is PPS?
Prospective Payment System
26
Who enacted the PPS? When?
Federal goverment in 1983
27
How are hopsitals paid under PPS?
Pre-determined rate for each Medicare admission according to the patient's DRG
28
Who controls PPS?
CMS under HHS
29
What is DRG?
Diagnostically Related Group - patient's will fall into a DRG based on their medical condition
30
What type of setting are DRGs used in?
Inpatient setting
31
What is APC?
Ambulatory Patient Classification - reimbursement in the outpatient setting
32
What is CPT?
Current Procedural Terminology
33
What is CPT used for?
Code outpatient procedures and ancillary services such as radiology and laboratory
34
What numerical coding method is used for DRG?
ICD-10-CM
35
What is ICD-10-CM?
International Classification of Diseases, 10th revision, Clinical Modiciation
36
What do we primarily use CPT codes for?
Procedures
37
What is IRD?
Index of Radiologic Diagnosis
38
What is IRD used for?
Specimens
39
How to correct/amend a health record mistake?
Must be fixed by the author of the mistake Line out the error Write "error" Sign and date
40
Can the patient amend their health record?
Yes - can add additional amendments but can't change original
41
What must be inlcuded to get health records released?
Consent in writing: Who is receiving the info Pt name, address, birthdate, extent of information, signature
42
What is MQSA?
Mammography Quality Standards Act - more stringent procedures for keeping images and for how long
43
Are original records left at the court?
No, copies are made Copies can be sent through certified mail
44
What is HIPAA?
Health Insurance Portability and Accountability Act
45
Who and when enacted HIPAA?
Congress in 1996
46
When did HIPAA go into effect?
April 14, 2003
47
Who is the enforcment agency for HIPAA?
Department of Health and Human Services
48
Who writes and maintains HIPAA?
Office of Civil Rights
49
What organizations must comply with HIPAA?
Health care providers, health plans
50
What is PHI?
Protected Health Information - if information is not related to treatement, authorization is required
51
What is Accounting of Disclosure?
A record that indicates who received patients information, for what purpose and when released
52
What determines who may and may not be given information?
TPO - treatment, payment and operation needs (information may be given if it falls into these categories)
53
What is required on portable devices for PHI?
Security software Encryption of data Firewalls
54
What is Incidental Disclosure?
If you inadvertently over hear or see information about a patient that you don't need to know
55
When a child turns 18, the parent turns into the:
Advisor
56
Ethic investigations of ARRT:
2010-7 2011-13 2012-25 2013-30
57
What is FERPA?
Family Educational Rights and Privacy Act
58
What does FERPA protect?
Protects privacy of Student Education Records Rights to student transfer at 18 Rights include: -can inspect and review -can request school to correct

Intro to Radiography (15 decks)

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