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Flashcards in chapter 4 Deck (24):
1

Subpoena duces Tecum

"bring with you under penalty of punishment" a requirement that documents be delivered to a court or brought with you to court

2

insurance

the transfer of an obligation from one party to another, usually in exchange for a fee

3

actuarial tables

a comprehensive list of statistical data

4

upcoding

using an incorrect international classification of diseases (ICD) or current procedure terminology (CPT) code to gain a larger insurance payment

5

respondeat superior

"let the master answer" the employer is responsible for its employees

6

vicarious liability

liability w/o fault. being held accountable for ones action even though you committed no wrong

7

contract

an agreement between parties that the law will recognize

8

reasonable person standard

a legal standard used to determine whether the actions of a party are warranted

9

medical records used to

manage healthcare
track healthcare
provide clinical data
meet regulatory requirements
document healthcare

10

managing healthcare

reviewing patients medical history
-past diseases
-past treatments
-past response to care

11

tracking care

why a patient sought medical care
where a patient received care
what medical care was provided
when the patient received care
hoe the patient responded to care

12

providing clinical data

research
statistical information
public health officials

13

regulatory requirements

Joint Commision in Accreditation of Healthcare Organizations (JCAHO)
-Evaluates records
-determines compliance with standards
-required for Medicare/Medicaid

14

documenting

what to write
-medical approach
-legal approach

15

medical approach

pertinent information
who, what, where, when, and how
review the purposes of medical records serve

16

legal approach

legal document
possible use in lawsuits and trial
used to demonstrate what care was provided
used to refresh your memory
what is NOT written
subpoena ducus tecum

17

medical record ownership

dually owned by both the patient and the healthcare institution
-institution: paper
-patients: information
-Doctrine of professional discretion: allows a physician to decide whether to release a patients medical records or not
-hypochondriacs: a patients who have a preoccupation with disease and illness
- psychological/psychiatric records: with holding information for the safety of the patient

18

storage and retention

statue of limitations
legal maxim
20 years from last date of service

19

insurance

written for anything
car insurance example
actuarial tables
premiums

20

managed care

skyrocketing healthcare costs
economize healthcare spending
ICD codes: inpatient
CPT codes: outpatient
upcoding

21

legal document

any writing that provides information or ideasthat can be attributed to the author

22

malpractice insurance

all healthcare providers
employment provided malpractice insurance
respondeat superior
vicarious liability

23

elements required for contracts

offer: though of as a desire to enter an agreement
acceptance: the taking of the offer, does not require a verbal response
consideration: whether the parties have thought about what they are giving up when entering into a contract
- contractual capacity
-implied contracts
-reasonable person standard

24

statue of fraud

a law that indicates when a contract must be in writing in order for the courts to recognize that contract
-executors/administrator agreements
-Employement contracts
-interest in land
-the sale of any item $7,500 or more