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HIS > HEALTHCARE INFORMATION REGULATIONS, LAWS, AND STANDARDS pt 2 > Flashcards

HEALTHCARE INFORMATION REGULATIONS, LAWS, AND STANDARDS pt 2 Flashcards

1
Q

Laws and regulations governing privacy and confidentiality of patient info and record retention/authentication

A

LEGAL ASPECTS OF MANAGING HEALTH INFORMATION

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2
Q

stored in electronic forms and in diff types of media (digital images)

A

Patient record

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3
Q

governed by multiple state and federal laws and regulations in addition to those for licensure and certification.

A

Health care information (patient-specific information)

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4
Q

Authentication

A

signature on a document

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5
Q

involved burning or shredding

A

Destruction of records

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6
Q

Address the medical record as

A

a legal document,

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7
Q

file folder full of info kung san makikita previous HC services na naavail and even medicines and physicians na naghandle

A

Patient medical record:

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8
Q

“Guidelines for Defining the Health Record for Legal Purposes”

○ Define the legal health record (LHR) as the documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization

A

American Health Information Management Association (AHIMA)

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9
Q

Documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization.

A

LEGAL HEALTH RECORD (LHR)

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10
Q

Includes records of care in any health-related setting used by healthcare professionals while providing patient care services, for reviewing patient data, or documenting observations, actions, or instructions.

A

LEGAL HEALTH RECORD (LHR)

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11
Q

Healthcare services that includes records in any healthcare setting

A

LEGAL HEALTH RECORD (LHR)

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12
Q

LHR excludes:

A

Health records that are not official business records of a
healthcare provider organization

Records such as personal health records (PHRs) that are
patient controlled, managed, and populated.

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13
Q 
advance directives
○ anesthesia records
○ care plan
○ consent for treatment forms
○ consultation reports
○ discharge instructions
○ discharge summary
○ e-mail containing patient-provider or provider-provider
communication
A

Examples of documentation found in the LHR:

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14
Q

Data from which interpretations, summaries, notes, etc., are derived.

A

PATIENT-IDENTIFIABLE SOURCE DATA

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15
Q

analog and digital patient photographs for identification
purposes only
○ audio of dictation
○ audio of patient telephone call
○ diagnostic films and other diagnostic images from
which interpretations are derived
○ electrocardiogram tracings from which interpretations
are derived
○ fetal monitoring strips from which interpretations are
derived
○ videos of office visits
○ videos of procedure
○ videos of telemedicine consultations

A

Examples of patient-identifiable source data:

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16
Q

Patient-identifiable data used for administrative, regulatory, healthcare operations, and payment (financial) purposes.

A

ADMINISTRATIVE DATA

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17
Q

Patient identifiers, biometrics, medical record (?)

number

A

Other knowledge source that do not imbed patient data

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18
Q

authorization forms for release of information
○ birth and death certificates
○ correspondence concerning requests for records
○ event history/audit trails
○ patient-identifiable claim

A

administrative data

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19
Q

Consists of information aggregated or summarized from patient records so that there are no means to identify patients

A

DERIVED DATA

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20
Q

Majority of states have specific retention requirements for health care information.
● These state requirements should be the basis for the health care organization’s formal retention policy.

A

RETENTION OF HEALTH RECORDS

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21
Q

When no specific retention requirement is made by the state, all patient information that is a part of the LHR should be

A

maintained for at least as long as the state’s statute of limitations or other regulation requires.

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22
Q

“Recommended retention standards”
○ state that patient health records for adults should be retained for ___ after the most recent encounter and patient health records for children should be retained until the time the person reaches the ____ plus the time stated in the relevant statute of
limitations.

A

Ten years

Age of majority

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23
Q

BASED ON AHIMA: (DEstruction gudelines)

A

Destroy the records so there is no possibility of
reconstruction.
■ Burn, shred, pulp, or pulverize paper.
■ Recycle or pulverize microfilm or microfiche.
■ Pulverize write-once read-many laser disks.
■ Degauss computerized data stored on internal or
external magnetic media (that is, alter the magnetic alignment of the storage media, making it impossible to recover previously recorded data)

24
Q

Document the destruction.

A 
■ Date of destruction.
■ Method of destruction.
■ Description of destroyed records.
■ Inclusive dates of destroyed records.
■ A statement that the records were destroyed in the
normal course of business.
■ Signatures of individuals supervising and
witnessing the destruction.
25
Q

Maintain the destruction documentation indefinitely.

A

True

26
Q

Joint Commission Hospital Accreditation Manual defines authentication as

A

“The validation of correctness for both the information itself and for the person who is the author or the user of the information”

27
Q

Regardless of rules and regulation, we need standard guidelines for e-signs

A

True (Electronic signatures)

28
Q

Make sure e-sign has a password so that signature will not be imitated

A

True

29
Q

Generally, a provider is required to have a sign stating that
he/she is the only person who has possession of that
signature and only one who can use it

A

True (Electronic signatures)

30
Q

Created when the provider enters a unique code, biometric, or password that verifies his or her identity.

A

Electronic signatures

31
Q

An individual’s constitutional right to be left alone, to be free from unwarranted publicity, and to conduct his or her life without its being made public.
● Individual’s right to limit access to his or her health care information.

A

Privacy

32
Q

The expectation that information shared with a healthcare provider during the course of treatment/healthcare will be used only for its intended purpose and not disclosed otherwise.

A

Confidentiality

33
Q

should be one of the important aspects na kailangan maprovide sa patient that would reflect your professional integrity and ethics

A

Medical Confidentiality

34
Q

reflect your professional integrity and ethics

A

Medical Confidentiality

35
Q

work hand-in- hand to provide safety to patient and employee

A

Privacy, trust, confidentiality, and security

36
Q

Philippine AIDS Prevention and Control Act of 1998

All results of HIV/AIDS testing shall be confidential.

A

RA 8504

37
Q

provides more avenues on how persons living
with HIV could try to avail diff services and clarifies gray
areas found in the previous RA

A

RA 11166

38
Q

Purpose of both: safeguard health of those with HIV

A

RA 8504 RA11166

39
Q

Pertains to more equitable financing through major sources like PhilHealth, life insurances, and personal savings

A

HEALTH FINANCING

40
Q

Health financing is a

A

Tax-based budgeting system largely finance public sector and national and local governments deliver those services

41
Q

social health insurance - financial health insurance protection for the Filipino people.

A

PHILHEALTH

42
Q

Financial protection is limited

A

resulted to a high

household out of the pocket payment

43
Q

The government pursues universal health coverage
because of the rapid expansion of membership in the
past

A

5 yrs

44
Q

Government health expenditure have

A

increased

45
Q

FOUR MAIN SOURCES OF FINANCING

A
  1. National and local government
  2. Insurance (government and private)
  3. User fees/out of pocket
  4. Donors
46
Q

Monetary drives for community development

A

Donors

47
Q

Increase responsiveness and client satisfaction

A

HEALTHCARE DELIVERY SYSTEM

48
Q

Enables all citizens to receive healthcare services when

needed in a cost-effective manner

A

HEALTHCARE DELIVERY SYSTEM

49
Q

Dual health delivery system:

A

public and private sectors

for both diagnosis and treatment

50
Q

Public (government institution) and private sector

A

Health facilities

51
Q

DOH supervises

A

Governemnt, corporate hospitals, specialty hospitals,regional hospitals

52
Q

DND runs

A

military hospital

53
Q

At the local level (Provincial government) runs

A

district / provincial hospitals

54
Q

At the local level (Municipal government) runs

A

Provides primary health care through rural health units and barangay health center / barangay health stations

55
Q

Highly urbanized and independent cities provide

A

both

hospital services and primary care services

56
Q

Prevention and promotion of health services and other

health-related programs thru

A

Rural health units

HIS (7 decks)

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