Unit 1

Question 1

Medical Record

Answer 1

• contains info on treatment by healthcare provider
• legal doc
• used for treatment/billing purposes

Question 2

EHR

Answer 2

• computerized lifelong healthcare record for a patient

• contains data from all sources to provide treatment
• maintained by multiple providers/ facilities

Question 3

EMR

Answer 3

• electronic medical record

- maintained by 1 provider

Question 4

PHR

Answer 4

personal medical record

-maintained by patient

Question 5

Why transition to EHR

Answer 5

• medical errors:
- handwriting, medication/surgical

• communication problems:
- misfiled, duplicate tests, coordination of care

Question 6

HIPAA

Answer 6

• federal law that governs the use, transfer and disclosure of identifiable health info
• passed because patient care info was being used in ways that violated their privacy

Question 7

PHI ( protected health info)

Answer 7

•individually identifiable health info
•protects info in any form
- paper, electronic, spoken, dead/living, recorded

Question 8

Covered Entity

Answer 8

any organization that directly handles PHI

Question 9

notices of privacy practices

Answer 9

• given on 1st encounter with health agency and at least once every 3 years after (or change in practice)
• describes patients rights under HIPAA

Question 10

HIPPA principles

Answer 10

governed by 2 main practices:
> need-to-know :
- what info do you need to know to do your job
> minimum necessary:
- are you using or disclosing the smallest amount of PHI necessary to complete the job

Question 11

de- identifying information

Answer 11

• anything that could be used to identify patient must be removed from any shared documentation
> expectations = public health , law enforcement, natural security situations

Question 12

what is used to identify a patient ?

Answer 12

• name
• geographic
• all elements of date (expect year)
• phone/ fax numbers
• email address
• numbers (social security)
• full face photographs/complete type

Question 13

disposing PHI

Answer 13

-secure way
>documents = shredded/incinerated
> not be placed trash cans/recycling
> hard drives wiped clear

Question 14

examples of HIPAA violations

Answer 14

• accessing health info of coworkers, family, celebs
• telling patient info
• sending PHI over emails

Question 15

patients rights under HIPAA

Answer 15

-right to request alternative communications ( voicemail)
- right to ask for changes for
medical/billing records

Question 16

non-compliance with HIPAA

Answer 16

• fines= up to $50,000 for each violation per year

* individual criminal penalties=up to 15 million dollars + prison for 10 years

Question 17

health info and data

Answer 17

-demographic info
-clinical info
> procedures
> diagnosis
> allergies
> diagnostics test results
> treatment plan

Question 18

results management

Answer 18

access to current/past test

results performed by anyone involved in treatment of patient

Question 19

order management

Answer 19

able to send,receive and store orders for medications,tests, and other services by any provider involved in treatment

Question 20

decision support

Answer 20

• computer based access to lasted clinical research

* computer based access to latest info on medication

Question 21

electronic communications

Answer 21

•provides easy access to emails for healthcare provider

- provider-provider 
- team coordination 
- patient-provider 
- external partners ( insurance)

Question 22

patient support

Answer 22

• offers patients access to appropriate educational materials
• offers patient ability to report to their physicians on home monitoring/testing

Question 23

administrative process

Answer 23

• scheduling management (appointments)
• Eligibility determination (insurances)
• medical coding

Question 24

Reporting / Population Management

Answer 24

• assists in detecting threats to health of the general population
• Epidemics
- Bioterrorism

Question 25

24 hour clock (military time)

Answer 25

- used to prevent confusion - numbers 1-24 instead of 1-12 - last 2 numbers = minutes - always 4 digits without colon

Question 26

Progress Notes

Answer 26

written statement about a patients care | - each medical facility implements certain type of progress notes

Question 27

SOAP notes

Answer 27

``` format for charting • Subjective • Objective • Assessment • Plan ```

Question 28

Subjective

Answer 28

Info obtained from what the client says - clients family perception - cannot be observed by healthcare provider - use quotes

Question 29

Objective

Answer 29

• info that's measured/observed ex= vital signs • no opinion •measurable

Question 30

Assessment

Answer 30

* interpretation/conclusions drawn about the subjective and objective data * should describe clients condition/progress

Question 31

Plan

Answer 31

The plan of care designed to resolve stated problem

Question 32

Effective Communication

Answer 32

• shared meaning and understanding between 2 people - communicator must consider their audience •requires listening,speaking, reading,observing, writing skills

Question 33

Listening skills

Answer 33

- face sender - eye contact - attention on speaker - ask for clarification - don't interrupt - be comfortable with periods of silence

Question 34

Speaking skills

Answer 34

- speak clearly and distinctly - speak to listen - choose words that audience will understand - talk "with" your listener and not "at" them

Question 35

Reading skills

Answer 35

- vocabulary | - progress notes,graphs,manual and research

Question 36

Observations skills

Answer 36

- looking for messages that aren't spoken - nonverbal messages - be mindful of your facial expressions

Question 37

Writing skills

Answer 37

- clear - concise - accurate