W6 ~ Confidentiality, Documentation, and HIPAA

communication in healthcare

• ____ communication (with patients, families, and providers)

• ______ communication (EMR notes)

• _____ communication (telehealth, emails)

verbal

written 

virtual

EMR (electronic medical record) uses

1) _____: use to record patient data

2) ____: for example in a trial, the medial records can be used…the more detail provided the more helpful.

clinical

legal

3) ____________: access to the patient chart to properly put together the bill/cost for care

4) ________: people who don't directly work with patients but still need access to records to improve their care. Ex: being a higher up and giving feedback after looking at records; collecting data from multiple hospitals to determine trends in the hospitals, and what some hospitals are doing well and what others are not doing well.

reimbursement

operations

5) ________: using patient cases for learning purposes

6) ________: having access to many patients’ medical histories can help in surveys or research projects. Serves as data

education

research

EMR Addendums

• all access is ________

• nothing can ever be _______

• edits notated with….

recorded

deleted

strikethrough

types of medical records

SOAP notes =

subjective, objective, assessment, plan

Subjective: what the patient tells you about how they ___, past _____ and _____ history, ___ _______

feel; medial; social; chief

Objective: everything you __, ___, ___, ___, and ___ from tests and procedures

see; hear; feel; smell; learn;

Assessment: using ___ collected to form a list of patients’ ________

data; problems

Plan: ______________ & ________ of _____

implementation; evaluation; results

patient confidentiality & medical-legal

HIPAA =

Health Insurance Portability and Accountability Act of 1996

Portability: gives certain ________ when an individual’s health care ________ changes

protection; coverage

Accountability: _____ of patient’s information

privacy

Under HIPAA those that use or disclose individually identifiable health information, known as ________ health information, are subject to the HIPAA ______ rules

protected; privacy

Before HIPAA, no ______ standard existed for the _________ of a person’s ________ information. With the implementation of these privacy rules on April 14, 2003, a minimum level of ________ was created nationwide

national; protection; medical; protection

The Joint Commission (TJC)

• standards for documentation

  • content _____

  • level of ____

  • ________

charted

detail

frequency

Negligence

Definition: A failure to behave with the level of ____ that someone of ordinary prudence would have
exercised under the same ____________.
The behavior usually consists of ______, but
can also consist of _______ when there is
some duty to act

Requirements: 

Defendant owed a duty of ____ to the plaintiff
Defendant ________ that duty
Plaintiff suffered a ______ recognizable ____
Defendant’s ______ of duty of ____ caused the
plaintiff’s _____.

care; circumstances; actions; omissions

care

breached

legally; injury

breach; care; injury