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Ethics Chapter 7
| Question | Answer |
|---|---|
| What is a medical record? | a collection of data recorded when a patient seeks medical treatment. |
| What is an EMR? | a digital version of the paper charts in the clinician’s office. |
| What is an EHR? | is built to share information with other health care providers, such as laboratories, specialists, and hospitals so that the patients’ total health information is in one record. |
| The content of the health record includes? | Patient Identification Information, Insurance information, Consent forms, Clinical data, Other administrative information |
| The Five Cs | Concise, Complete, Clear, Correct, Chronologically ordered |
| What Is a correction? | a change in the information that is meant to clarify inaccuracies found after the document is complete. |
| Steps to make a correction | Draw a line through the incorrect information so that it is still legible. Write in the correct information. Sign or initial, date, and time the entry. If possible, ask another staff member to witness the correction. |
| What is an addendum? | new documentation used to add information to the original entry. |
| What is an amendment? | used to clarify or correct information in the electronic health record. |
| Who owns a patient medical record? | State laws vary, but it is generally accepted that the provider/facility that created the record owns it. |
| What is the doctrine of professional discretion? | A principle under which a physician can exercise judgment as to whether to show patients who are being treated for mental or emotional conditions their records. |
| What is the Destruction requirement? | there is no single standard destruction requirement. |
| Examples of common destruction methods? | burning, shredding ,recycling and pulverizing, demagnetizing, cutting |
| Medical records should not be released to a third party without? | written permission signed by the patient or the patient’s legal representative. |
| Why are patient medical information often released? | Insurance claims, transfer to another physician, use in a court of law |
| The patient has a right under HIPAA? | to see and get copies of the person’s health information, and to share it with a third party, such as a family member, other doctors, or even with a mobile app. |
| health information technology | The electronic systems health care professionals—and increasingly, patients—use to store , share, and analyze health information |
| Meaningful use | A process by which health care providers use an electronic health record according to guidelines set by the federal government |
| Telemedicine | is the exchange of medical services and information using electronic communication. |
| Telemedicine provides the following services? | Primary care and specialist referral services, Remote patient monitoring, Consumer medical and health information, Medical education |
| How long should medical records be kept? | Laws vary with states, but records should be kept for the minimal statute of limitations period, plus any specified time. |
| What is HIT? | The electronic systems health care professionals—and increasingly, patients—use to store, share, and analyze health information. Health IT includes EHRs, PHRs, electronic prescribing (e-prescribing), and privacy and security of the EHR. |
Created by:
Cedesro12