FMIS102 W9&W10 Quizlet

What are Active Patient files?

Files of patients who are being actively seen within the specific healthcare facility.

What does EMR stand for?

Electronic Medical Record

What does the EMR contain?

Electronic medical records that contain medical and health records of individual patients

(T/F) EMR's are shared with with other healthcare professionals outside of that practice.

FALSE- Only within the practice

What does EHR stand for?

electronic health record

What are EHR records

Electronic medical records that can be shared, created, managed, and consulted by authorized healthcare providers, professionals, and staff across more than one healthcare organization

What does PHI stand for?

Protected Health Information: "individually identifiable health information"

What does SOAP stand for?

S: Subjective

O: Objective

A: Assessment

P: Plan

Besides SOAP, what is another common type of medical record documenting format:

CHEDDAR

(T/F) Ownership of a Patient's medical record belongs with the facility or Healthcare provider

TRUE

How long is medical information normally held for?

Minimum of 10 years

What outlines the minimum number of years records should be kept?

The State's Statutes of Limitations on Medical Records

What is considered an Inactive patient file?

A file for a patient who has not sought treatment for a period of time or one who completed his or her course of treatment, usually longer than 3 years.

What is the purpose of accurate Medical Records:

• providing the patient's past and present medical history as a Continuity of Care Record (CCR),

• allowing members of the healthcare team to communicate with one another,

• protecting both the patient and healthcare professional in cases of negligence and malpractice,

• serving as research and quality control, and

• providing documentation for billing and coding purposes for insurance claims.

Fill n the blanks: Health Insurance _____________________ and ______________________________ Act of _____________

Portability, Accountability of 1996

(T/F) private insurances are part of the specific government plans that have their own set of retention periods

FALSE- see box 9.2 in your book

(T/F) HIPAA consists of six (VI) titles

FALSE- It has 5 (V)

Which Title is the most relevant for healthcare professionals and organizations:

Title 2 (II), because it focuses on privacy and security of health information.

Is an email, Fax and IP address considered as PHI?

YES

Under the security rule, what areas should be secured to protect PHI?

1)Computers/workstations

2)Data storages

3) Documents sent and received (faxes, hand written doctor's orders)

4) Properly removing all client data from hardware or software before disposing of it

5)Limiting access to outside people

Why is mandatory reporting Important?

for the protection and welfare of the general public, as well as specific vulnerable populations

What items/events are considered as mandatory when it comes to reporting?

• Births

• Deaths

• Communicable diseases

• Assaults or criminal acts

• Abuse—child, elder, and intimate partner

• Substance abuse

(T/F) Birth certificates and Certificate of Life Birth are the same thing.

False- Certificate of life is an unofficial birth certificate

What process makes the certificate of live birth an official birth certificate?

When it is sent to and verified by the local county's clerk's Office

What federally operated agency mandates the communicable diseases are reported?

The Center for Disease Control (CDC)

What is a communicable disease?

Specific disease or illness that can cause an epidemic or pandemic to the general public.

What are some communicable diseases?

• Tuberculosis

• Rubeola

• Rubella

• Tetanus

• Diphtheria

• Cholera

• Rheumatic fever

• Poliomyelitis (polio)

• Acquired immunodeficiency syndrome (AIDS)

• Meningitis

• Certain strains of the influenza virus, such as swine flu

• Sexually transmitted diseases

• Zika virus

(T/F) Some of communicable diseases do not require HIPAA release from the patient.

TRUE- Tuberculosis, Chickenpox and others

What is Contact tracing?

the process to identify, monitor, and support individuals who may have been exposed to a person with a communicable disease.

List forms of Abuse

1)Physical

2)Verbal/Emotional

3)Psychological

4)Sexual

5)Economic

(T/F) Psychological abuse is pushing, hitting, shoving, punching, biting, choking, and physically trapping or impeding movement

FALSE- answer is Physical

What type of abuse includes criticizing, degrading, swearing, blaming, attacks that harm self-esteem

Verbal/Emotional abuse

What type of professions are required mandatory reporting for child abuse?

Social workers

• Teachers, principals, and other school personnel

• Physicians, nurses, and other healthcare professionals

• Counselors, therapists, and other mental health professionals

• Childcare providers

• Medical examiners or coroners

• Law enforcement officers

(T/F) You must have proof and be certain of child abuse before reporting it

FALSE- the healthcare professional does not have to provide proof that abuse or neglect has occurred

Can penalties, fines or imprisonment be imposed on healthcare professionals that fail to report suspected child abuse.

YES

Why is child abuse reporting important?

To protect and prevent endangering children

It is projected that ______ out of_______ people older than the age of 60 years has experienced some form of abuse, neglect, and exploitation

1 out of 10

What is Domestic Violence?

is any abusive act between family members, ex-spouses, intimate cohabitants, former intimate cohabitants, dating couples and former dating couples in which one party seeks to gain/maintain power and control over the other partner

What is IPV?

intimate partner violence- IPV describes physical, sexual, or psychological harm by a current or former partner or spouse and can occur between heterosexual or same-sex couples and does not require sexual intimacy

What is nonintimate partner violence?

which is violence between individuals who are not intimate partners, but have a familial relationship, such as mother/daughter or son, or brother/sister

What is Addiction?

compulsive behavior in which a person engages in a habit or action despite its negative consequences and effects

Drug can be classified using _____ schedules

5 (I -V)

(T/F) Schedule I drugs have the least potential for abuse

FALSE-They have the greater

List a few Narcotics from Schedule I:

1)Heroin

2)PCP

3)LSD

(T/F) Amphetamines, morphine, codeine and Opium are considered Schedule II.

TRUE