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It is necessary to keep accurate medical records because
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| they provide critical information for other caregivers, the effects of various treatments can be tracked and are vital for financial reimbursements. They can also offer protection to the physician during legal proceedings and can be used for statistics |
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The patient’s medical record should never
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Whatever medical record system is used in the facility, it should provide for
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| easy retrieval of records and must work for the individual facility, first and foremost |
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· When preparing a file for a new patient, the medical assistant should
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| review the forms for completeness, double check for the correct spelling and copy the insurance card |
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· When adding documents to the patient chart, the most recent information should . |
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· Medical records must be completely . |
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| legible and authenticated properly |
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By legal definition, if it isn’t charted, |
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The validity of health data is
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· To correct charting errors
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| draw a single line through it, insert the correction above or immediately after the error, initial and date the error correction; do not hide charting errors. |
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· Continuity of care means that it continues smoothly from one provider to another, so that
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| the patient receives the most benefit |
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· An informed consent form must
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| address the risks and benefits of the procedure, reasonable alternatives to the procedure, risks and benefits of not performing the procedure |
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A provisional diagnosis is one that is
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| not a final diagnosis and is usually made before test results are received |
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| What the patient tells you |
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Definition
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| a hospital acquired infection |
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· When selecting filing equipment the medical assistant should consider the |
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| cost of space and equipment, fire protection, and confidentiality requirements |
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Definition
| an indirect filing system, which offers extra confidentiality |
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Advantages to color-coding filing systems are:
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Definition
| that the patient charts can be found and re-filed quickly and it is easy to tell when a file is misplaced |
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· Releasing a record, with regard to filing it, means |
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| placing a mark indicating that the item is ready for filing |
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· An OUTfolder is used to
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| provide space for the temporary filing of materials |
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· The method of filing whereby one report is laid on top of the older report, resembling a roof is called
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Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called
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How would you properly index the name “Robert Williams, MD” for filing if you had another patient with the same name, but without the title |
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Williams Robert
it would be filed first |
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How would you properly index the name “Erica M. Johnson-Wilson” for filing |
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Keep a copy of a patient consent form in
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Health information management is
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| a relatively new profession |
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· Health information professionals |
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| collect, interpret, and analyze data |
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Quality assurance is defined as
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| the activities designed to increase the quality of a product or service through process or system changes that increase efficiency or effectiveness |
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Quality assurance is concerned with
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Definition
| overuse (antibiotics), underuse (mammograms), and misuse of medical services |
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Most healthcare organizations today strive to
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| exceed quality standards, not just meet them |
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All employees must make a commitment for
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| total quality management to be effective |
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HIPAA was developed in part to
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Definition
| assure the confidentiality of medical records |
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· HIPAA compliance is everybody’s responsibility in
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Employees in healthcare facilities must be trained so that
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| they understand the procedures related to HIPAA compliance |
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· An organization that transmits information in an electronic form during a transaction is defined by |
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| HIPAA as a covered entity |
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Patients have a right to notification of
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| a facility’s privacy practices |
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A Notice of Privacy Practices must include
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Always document any form of communication about the patient’s preferences in
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Because of HIPAA regulations, patients |
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| have more control over their medical records. They have the right to restrict any parts of their PHI |
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· Providers must review requests for amendments of PHI and act on them within |
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· The medical record should be released only with a
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| written release from the patient |
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· Medical facilities should keep records on minors until
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Definition
| the minor reaches the age of majority, plus 3 years |
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· HIPAA recommends that physicians keep the records on patients who have died for at least
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Definition
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Term
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Definition
| nonprofit organization that assists healthcare facilities by providing accreditation services |
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· When sending health information via fax the MS should always
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Definition
| verify the fax number, direct the fax to a certain person, and use cover sheets that stress confidentiality. |
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Term
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Definition
| protected health information |
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