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MAA 104

Final Review

Why do we keep records? #1 Legal Use. Medical records are legal documents and can be subpoenaed. They can be used in malpractice suits.
Why do we keep records? #2 Medical records evaluate quality of treatment
Why do we keep records? #3 Provide for continuity of care.
Why do we keep records? #4 Allows for communication between provider and staff.
Why do we keep records? #5 Documents the patient's original evaluation.
Why do we keep records? #6 Reports any changes in the patient's condition
Golden Rule of Documentation? If it didn't get documented it didn't happen.
Release of Information Should not be done over the phone. Should not be transmitted unless over a secure line or it is encrypted.
Ownership of records In private practice where there is ONE physician: The physician owns the physical chart. In group practice, the clinic owns the physical chart. The PATIENT owns the information in the chart.
Correction of a record Never use white out. Draw a single line through the error. Make the correction. Sign and date the correction.
Chart Status: Active Patients currently being seen
Chart Status: Inactive Patients not been seen recently (up to 3 yrs) (After 3 yrs, New Patient)
Chart Status: Closed Deceased patients, Patients that won't be seen anymore (Moved, Fired, Etc.)
Abbreviations Only use those accepted by facility. Standard Medical Abbreviations.
AMA Recommendations Train Employees in HIPAA & Confidentiality. Conduct audits of employee movement through records. Prepare back up plan
Security Don't open emails that you don't recognize the sender. Change passwords
Flow Sheets Record ongoing measurement
POMR chart Problem oriented medical record. Listed and assigned numbers. Recognize component list: Database, problem list, treatment plan, progress notes
SOAP chart S)ubjective Patient Info - What pt. tells you is worng O)bjective clinical measurements - BP, weight, temp A)ssessment/Diagnosis P)lan for treatment
Late Documentation Document note with current date but chart for late entry for date and time of occurrence.
Progress Notes Documentation of every patient encounter. Including phone calls and prescription refills.
Advance Directive Living Will
HIPAA Title 1 Covers health insurance access and portability & renewal. Those who fall under are called covered entities. Covered entities are: Healthcare Workers, Insurance Cos., Clearinghouses. HIPAA officer: oversees all aspects of compliance
Demographic Info
Narrative: Paragraph indicating contact with patient
Diagnosis: Disease or condition identified in a patient
Chronological Order: Place in order of time (date) most recent
Referral: Instruction to transfer a patient's care to a specialist.
Medical Impression: Conclusions drawn by the physician from the interpretation of data
Health History Report: Provides subjective data to assist in diagnosis.
Chief Complaint: The problem that is causing the patient to seek medical treatment (in their own words). Found in the clinical section of the chart. Main reason foe the medical office visit.
Objective Symptom: A symptom that can be observed by the examiner(or measured) i.e. temp, rash, BP, etc.
Subjective Symptom: Symptom felt by the examiner, but not observed by examiner.
Physical Exam Report: Report of a physician's objective findings.
Prognosis: Probably course and outcome of a patient's condition.
Business Letters Use only standard abbreviations
Clearinghouse Entity that receives, reviews, sends and manages claims
Written correspondence
How do you secure email? With an encryption feature
How many formats for business letters? 4 (clearinghouses, record classification, chief complaint, medical records)
Record Classification Active, Inactive, Closed
Chief Complaint Subjective
Patient registration -Administrative info Collecting demographics does not include clinic info
Can we copy anything on the internet? NO. Copywrite laws apply.
Created by: JDenning8984