Written Comm & HIPAA review

What is one of the reports you will NOT be creating?

Diagnostic reports

What are the 3 correct formats for creating a correspondence or document?

Block / Semi block / Full block

What are two standard elements in the creation of a memorandum?

Date and Copy

What is the standard envelope for the USPS?

#10 (9-1/2" long x 4-1/8" high)

A written communication must be?

Clear, Concise, and Correct

What is the earliest age you are allowed to get copies of your medical records if you are not an emancipated minor.

18 in the state of MI

Who does the medical record legally belong to?

The provider/physician

What are the key features associated with EMR/EHR?

Improved communication, Point of care charting, Medication management, Clinical decision making.

What does the acronym SOAP stand for?

Subjective, Objective, Assessment, Plan

Three qualities of a medical record that are helpful in a lawsuit.

Timely accurate and legible

Four potential drawback for the implementation of EMR

Cost, Training time, Possible software or hardware failure/malfunctions, Inputting paper data correctly

Should you always use your complete name and credential as well as recording the date?

Yes

Is it possible to release certain patient information without a patient release?

Yes, for legal purposes. (legally required disclosures)

True or false Numbers in a correspondence should generally be spelled out

True

True or false Roman numerals are usually changed to word.

False

True or False Letters you may write don't have to follow HIPAA privacy rules.

False, privacy rules MUST be followed

True or False Spell check is the best way to proofread a correspondence

False

True or False Salutations and closing are generally used when writing a memorandum.

False

True or False The golden rule of abbreviation is “When is doubt spell it out”

True

True or False The purpose of an agenda is to let everyone know when lunch is.

False

True or False when taking minutes, you need to be sure to include personal opinions. 

false

True or False Wrong information on a correspondence could lead to injury or lawsuit for the provider.

True