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Health Records CH.12
Study Guide on Chapter 12 - Health Records
| Question | Answer |
|---|---|
| Age of majority | The age at which the law recognizes a person to be adult; it varies by state |
| Anthropometric | Pertaining to the measurement of the size & proportions of the human body |
| Compliance | Meeting the standards and regulations of the practice's established policies and procedures. Can also means cooperation |
| Continuity of care | The smooth continuation of care from one provider to anotehr. This allows the patient to recieve the most benefit with no interruption or duplication of care |
| Demographics | Patients health record and/or Informational detail |
| Diagnosis | Determining the cause of condition |
| e-prescribing | The use of electronic software to communicate with pharmacies and send prescribing information |
| Incidence | How often something happens or occurs |
| Prognosis | The likely outcome of a disease, including the chance of recovery |
| Progress notes | Documentation in the medical record to track the patient's condition and progress |
| Objectivre information | Data obtained through physical examination, laboratory and diagnostic testing, and by measurable information |
| Subjective information | Data or information obtained from the patient, including the patient's feelings, perceptions, and concerns; this information is obtained through interview or written question |
| Tickler file | A chronological file used as a reminder that something must be dealth with on a certain date |
| Be able to recognize subjective and objective information (examples) | Subjective: Patient said, "I'm feeling sick and want to throw up" Objective: The BP of the patient is 130/80 |
| Give two examples of past health history | The patient have an illness (e.g. chickenpox) when they were a child The patients previous surgeries (gastroectomy) |
| Give two examples family history | The patients grandparents had a heart problem The patients parents had a diabetes |
| Give two examples of social history | The patient use alcohol and drugs The patient do not exercise |
| What is the chief complaint? | Patient's own word of symptoms or what they feel |
| Who owns the medical record? | The physician/doctor |
| What is eligibility verification? | EHR billing systems can perform online verification of insurance eligibility and capture demographic data |
| Three classifications of records | Active: Records of patient currently receiving treatment Inactive: Records of patinet provider not seen for 6 months or longer Closed: Records of patients who died, moved away, or other-wise terminated their relationship with the provider |
| The process of moving a file from active to inactive is called | Purging |
| When no rules specify the retention of health records, the course is to keep the records for | 10 years |
| What does SOAP stand for? | Subjective Objective Assessment Planning |
| How can patients access their healthcare information electronically? | Patient Portal |
| What does a patient need to fill out before his/her healthcare information can be released to a third party? | Patient Release Form |
| If an error is made in the paper health record, how is it corrected? | One line over the error Put the right naswer on top Put the data and your initials |
| How do you handle an error that is made in the electronic health record? | Make an Addendum |
| What are the three basic filling methods in healthcare facilities? | Alphabetic by name, Numeric, Subject |
| Which is the oldest, simplest, and most commonly used filling method? | Alphabetic filing |
| What is important to remember when documenting in the EHR system? | It must be proofread before submission |
| Electronic Health Record (EHR) | Relates to Multiple healthcare organization The system |
| Electronic Medical Record | Relates to Single healthcare organization The chart |
| Health records are kept for five basic reasons: (1-3) | 1. To provide the best possible medical care for the patient 2. To provide critical information for others 3. To provide legal protection for those who provided care to the patient |
| Health records are kept for five basic reasons: (4-5) | 4. To provide statistical information that is helpful to researchers 5. To provide support for claims reinbursement |
| The medical record is a legal document (TRUE OR FALSE) | TRUE |
| AMA | American Medical Association Agaisnt Medical Advice |
| CPOE | Computerized Provider Order Entry |
| CPT | Current Procedural Terminology |
| EHRs | Electronic Health Records |
| HHS | The Department of Health and Human Services |
| HIE | Health Information Exchange |
| HIPAA | Health Insurance Portability and Accountability Act |
| HIV | Human Immunodeficiency Virus |
| ICD | International Classification of Disease |
| NPP | Notice of Privacy Practices |
| ONC | The Office of National Coordinator for Health Information Technology |
| PCP | Primary Care Physician |
| PHI | Protected Health Information |
| PHR | Personal Health Record |
| POR | Problem-Oriented Medical Record |
| SOR | Source-Oriented Medical Record |
| TPR | Temperature, Pulse and Respiration |
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