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Chapter 1
Medical Record and Health History
Question | Answer |
---|---|
Good documentation: | Works to legally protect the provider and medical staff |
Incomplete records: | Can be used as evidence to show that the patient did not receive quality care. |
Information is strictly confidential: | Must not be read or discussed by anyone not involved in the care of the patient. |
HIPAA: | Health Insurance Portability and Accountability Act. |
HIPAA Privacy Rule: | Federal law that protects patient's privacy. Went into effect April 14, 2003 |
Purpose of HIPAA: | Provide patients wtih more control over use and disclosure of their health information - known as PHI - protected health information. |
Who must comply? | Anyone who uses, stores, maintains or transmits health information such as Health care providers, health plans or healthcare clearinghouses eg. billing services. |
What is included in the HIPAA privacy rule? | |
Components of the Medical Record: | Consists of numerous documents. Each document has a specific function. |
Components of the Medical Record: | Documents often consist of preprinted forms and computer templates. |
Components of the Medical Record: | Documents can be classified into categories. |
Medical Office Administrative Documents: | Contain information for efficient record keeping of office. |
Patient Registration Record: | Consists of demographic and billing information. |
Patient Registration Record. | Must be completed by all new patients. |
Patient Registration Record: | MA enters this information into the computer. |
Patient Registration Record | Information is used for numerous computerized functions (e.g. scheduling appointments, posting patient transactions, processing patient statements and insurance claims. |
Original registration record | PPR: Placed in front of patient's medical record. |
Original registration record | EMR: Usually shredded (after MA enters information into computer. |
Patient Registration Record includes: | Demographic information: Full name Address Phone (home and work) |
Patient Registration Record includes: | DOB Gender Marital status Employer |
Patient Registration Record includes: | Billing Information Name of responsible party SSN Address of responsible party Name of insured Policy and group number. |
NPP Acknowledgement Form | Written document. |
NPP Acknowledgement Form | Explains to patients how their health information will be used by the medical office, protected by the medical office. |
NPP Acknowledgement Form | Patient must sign the form - acknowledges that he or she has received the NPP. |
NPP Acknowledgement Form | NPP is filed in the patient's chart. |
Correspondence: | May be received from Insurance companies eg precertification authorization. |
Correspondence | Patient's attorney. |
Correspondence | Patient. |
Correspondence | May be sent from office: >Patient referral letter >Collection letter. |
Medical Office Clinical documents" | Medical Office clinical documents: >Records and reports that assist the provider in care and treatment of patient. |
Health History Report: | > Subjective data about the patient. > Health history obtained by having the patient complete a preprinted form. > Provider or MA during an interview. |
Health History Report | Health history, physical and laboratory and diagnostic tests are used to: |
Health History Report | Determine patient's state of health. >Arrive at a diagnosis - the scientific method of determining and identifying a patient's condition. > Prescribe treatment. >Document change in patient's illness after treatment. |
Health History Report: | >Thorough history obtained on each new patient. |
Subsequent visits: | Provides additional information regarding changes in patient's condition and treatment. |
Physical Examination Report: | Physical examination assessment of each part of the patient's body. |
Physical Examination Report. | Purpose: provides objective data about the patient and assists the provider in determining patient's state of health. |
Physical Examination Report includes | A summary of the provider's findings from each part of the body includes: General appearance Head and neck Eyes |
Physical examination Report includes: | Ears Nose Mouth and Pharynx Arms and hands |
Physical Examination Report includes: | Chest and lungs Heart Breasts Abdomen |
Physical Examination Report includes: | Genitals and rectum Legs and Feet |
Progress Notes: | Purpose is to update medical record with new information when patient visits or telephones the office. |
Progress Notes: | Must include date and time and signature and credentials of individual making the entry. |
Progress Notes and Medical Record | Detailed information on patient's medications includes: Prescription medications, OTC medications and medications administered at the medical office. |
Purpose of Progress Notes is to: | Update medical record with new information when patient visits or telephones the office. |
Progress notes must include: | Date and time Signature and credentials of individual making the entry. |
Consultation Report is a: | Narrative report of clinical opinion about a patient's condition by a practitioner other than the primary provider (consultant). |
Consultation Report | Usually is a specialist (eg cardiologist). |
Consultant's opinion is based on: | Review of patient's record and examination of patient. |
Home Health Care Report | The provision of medical and nonmedical care in a patient's home. |
Home Health Care Report | Purpose is to minimize the effect of disease or disability on the patient by promoting health, maintaining health and restoring health. |
Home Health Care Report. | Home Health care must be ordered by the provider. |