Patient Care Unit 7 Medical Records

What is the purpose of medical records

effective communication

What is CMC

Center for Medicare and Medicaid Service

What is the purpose of CMC

states, the medical record must contain information to justify the visit

What are the medical records Big Three

Optimize best care

Quality business decisions

provides legal records for all involved

What is CPT

Current procedural terminology

What APC

Ambulatory Payment Classification

What is APC based on

based on ICD-10-CM codesFOR DIAGNOSIS

reimbursement in a outpatient setting

What is CPT-4 for 

medical terms and codes for DIAGNOSTIC and THERAPEUTIC 

What do ICD codes range in radiology

70010-79999

What does HIPAA stand for 

Health Insurance Portability and Accountability Act (1996)

What are the components that affect health information

Privacy

Security

Establishment of Standards 

Requirements for electronic transmission of certain health information

What is the Rules of ethics No.12

revealing a privileged communication relating to a patient

What is the Rules of Ethics No. 9

respects confidences entrusted in the professional practice, respects the patient’s right to privacy

What are the terms to quality assurance

Efficacy

Appropriateness

Availability

Timeliness

Effectiveness

Continuity

Safety

efficiency

respect and caring

Efficacy

activities achieved desired outcome

Appropriateness

is the activity relevant to our clinical needs 

Continuity

How are activities coordinated among providers over time

Ownership of medical records

owned by the caregiver or facility but patient has the right to the information