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Medical Law and Ethics
Chapter 9 and 10 - Quiz 4
32
Anatomy
Undergraduate 1
11/13/2017

Additional Anatomy Flashcards

 


 

Cards

Term
What 3 things are included in all written documents relating to patient?
Definition
  • Past history
  • Current diagnosis and treatment
  • Correspondence relating to patient.
Term

True/False

 

Medical records are legal documents and may be subpoenaed.

Definition
True
Term
4 purposes of the medical record:
Definition
  • Record of patient from birth to death
  • Document for continual management of patient's health care
  • Provides data and statistics on health matters
  • Tracks ongoing patterns of patient's health
Term
What 6 pieces of personal information about the patient are included in the medical record?
Definition
  • Full name
  • Address
  • Telephone number
  • Date of birth
  • Marital status
  • Employer and insurance information
Term
Federal reimbursement guidelines require that medical record be completed by physician within how many days following patient's discharge from hospital?
Definition
30
Term

True/False

"If it is not documented, it did not happen"

 

Definition
True
Term
Who owns the medical records?
Definition
Physicians or owners of the health care facility
Term
Patients have legal right of _______ ________ and access to records.
Definition
"privileged communication"
Term
How must patients authorize the release of their records?
Definition
In writing
Term
Doctrine or professional discretion:
Definition
Physician may determine, based on his or her best judgment, if patient with mental or emotional problems should view medical record.
Term
4 statements regarding the release of information:
Definition
  • Never send entire medical chart unless it is requested
  • Do not send original
  • Record may not be released to patient without physician's permission
  • Patient must sign release form for information to be sent to insurance company.
Term
How long do records have to be kept from time of last entry?
Definition

10 years

 

Minor's records must be kept until patient reaches age of maturity plus period of the statute of limitations.

Term
Improper disclosure:
Definition
Health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization
Term
Subpoena Duces Tecum:
Definition
Written order requiring person to appear in court, give testimony, and bring information described in subpoena.
Term
HIPAA
Definition
  • Health Insurance Portability and Accountability Act
  • 1996
  • Regulates the privacy of patient health information
Term
4 objectives of HIPAA:
Definition
  • Improve insurance portability
  • Combat fraud, abuse, and waste in healthcare
  • Promote the expanded use of medical savings accounts
  • Simplify the administration of health insurance
Term
Protected health information:
Definition
  • Past, present, future individually identifiable health information
  • Name, age, gender Social Security Number, zip code, e-mail
Term
3 exceptions to receiving patient consent for health care providers:
Definition
  • Emergency situation
  • Language barrier without an interpreter
  • Treating prison inmates
Term
An example of Denial of the Request for Privacy
Definition
SOme health care institutions, such as nursing homes, may have to deny access to a patient's medical information in order to protect the patient.
Term

True/False

 

Some states have stricter privacy standards than those of HIPAA.  In this case, state's law would take precedence over the Federal HIPAA regulation

Definition
True
Term
Employer Identifier Standard
Definition
  • Identifiers are used to reduce confusion and errors.
  • Published 2002
  • Uses employer's tax ID number or Employer Identification Number (EIN)
Term
How do you "de-identify" patient information?
Definition

Remove:

  • Patient's name
  • Address, including e-mail
  • Telephone and fax numbers
  • All dates, including birth (except year), admission, discharge, and death
  • Social Security number
  • Medical records numbers
  • Health care insurance numbers
  • License numbers
  • Facial photos
  • Other identifying numbers or characteristics
Term
Civil penalties for violating HIPAA:
Definition

(It is a federal crime)

  • Up to $100 per person, per incident for minor disclosures
  • Up to $25,000 for multiple violation of the same standard in a calendar year.
  • Federal criminal liability for improper disclosure of information or for obtaining information under false pretenses carries sanctions of up to $50,000 and one year in prison
  • Up to $250,000 and/or up to 10 years in prison for obtaining PHI under false pretenses with the intent to sell, transfer, or use the info for personal gain or for malicious action, such as Medicare fraud
Term
Health Integrity and Protection Data Bank (HIPDB)
Definition
National data bank collects reports and disclosure of actions taken
Term
7 Patients' Rights Under the Privacy Standards
Definition
  • Copy of privacy notice
  • Access to medical records
  • Limit how health care information is shared
  • Accounting of who information is given to
  • Ask to be contacted in a special way
  • Examine health information provider's copy
  • Complain to "covered entity" if violation of privacy is suspected
Term
Researchers must obtain:
Definition
  • Patient authorization that complies with HIPAA rules
  • Waiver of authorization from a privacy board or Institutional Review Board (must include extensive documentation as required by HIPAA)
Term
5 misconceptions regarding HIPAA:
Definition
  • Does not prevent physicians or hospitals from sharing patient info to treat
  • Does not prevent disclosure to clergy
  • Allows hospitals and physicians to share info with spouse or anyone patient has identified as involved in their care.
  • Does not apply to most police or fire department (may release info about accident victims)
  • Does limit info EMTs may disclose
Term
Recommendations:  (first 5)
Definition
  • Appoint and train privacy officer
  • Conduct internal assessment of existing policies
  • Enter agreements with all non employee service providers
  • Adapt procedures for handling patient requests 
  • Implement notice of privacy practices
Term
Recommendations:  (last 5)
Definition
  • Revise employee manuals regarding HIPAA standards
  • Train all employees on policies and procedures
  • Retain signed authorization and any agreements with patients restricting disclosure of PHI for a period of 6 years
  • Implement and enforce sanctions for filations
  • Establish complaint process for noncompliance
Term
Wireless local area networks (WLANS):
Definition
Communication system used to access patient records from central databases
Term
Medical informatics:
Definition
Application of communication and information to medical practice, research, and education.
Term
Telemedicine:
Definition
Use of communication and information technologies to provide health care services to people at a distance
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