HIPAA and Ethics and SOAP

What does HIPAA stands for

Health Insurance Portability and Accountability Act

when was HIPAA inctroduced

1996

What does HIPAA protect (general)

individually identifiable health information, PHI

PHI

protected health information

what does hipaa protect (specifically)

person’s name, address, birthday, social security number, their health conditions, the health services, and payments for the health services

What precautions should doctors follow for HIPAA

can’t speak about patient info or leave it easily accessible, can share with other people with patient consent

when can hipaa protected info be shared

needed for health coverage, public health laws, complying with workers compensation, needed for legal stuff, disaster relief, or cause of death

What does SOAP stand for

Subjective, Objective, diagnosis, plan

what is subjective in soap

info from patient

what is objective in soap

measurable data like vital signs, test results, or observations during exam

what does assessment in soap mean

diagnosis

what does plan in soap mean

treatment, tests, or follow ups

Why is medical charting needed

communication and legal needs

pt

patient

hx

history

c/o

complaints

ha

headaches

l

left

cc

chief complaint

sob

shortness of breath

y/o

years old

nka

no known allergies

bmp

beats per min

f/u

follow up

bp

blood pressure

c

with

dx

diagnosis

wnl

within normal parameters

dob

date of birth

what is the first rule of med charting

SOAP is part of notes

what is the 2nd rule of med charting

always use patient’s names, your names, title, date, and current time

whats the 3rd rule of medical charting

only use black ink and cross out and initial changes