ALH 106 FINAL Word Scramble

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Question	Answer
A medical record ordered by the court to be available during a malpractice case is	subpeona
Medical record management requires	accuracy confidentiality proper documentation proper storage proper filing
Patient information in the medical record should include	personal and clinical information
The medical record must include information about patient care such as	diagnosis prescription information test results physical examination
A private or public healthcare entity that facilitates the processing of nonstandard electronic transactions into HIPAA transactions is a	insurance company clearinghouse covered intity WLAN WI-FI
A healthcare organization covered under HIPAA regulations is a	covered entity
A number assigned to an employer for purposes of identification is the	EIN
The individual or group that provides or pays for the patient’s medical care is the	Healthcare plan
A national source of reports of actions taken against healthcare providers, practitioners, and vendors who are in noncompliance or performing fraudulent activities is the	healthcare integrity and protection data bank
Conditions such as cancer, epilepsy, and congenital disorders of the newborn are often reported to government agencies in order to	maintain accurate public health statistics
An incomplete medical record may	may be difficult for a healthcare provider to defend allegations in court
For the court’s purpose, if documentation does not appear in the medical record,	it did not occur
Medical records should not be released to the patient without	the physicians knowledge and permission
The Privacy Act of 1974 provides private citizens some control over what	information the government collects about them and limits the use of information for unneccesary purposes
Under the Privacy Act of 1974 individuals were given the right to	find out what information was collected about them by the government see and have a copy of the information correct and ammend information exercise control over disclosure of their informartion
The privacy act only applies to federal agencies and government contractors	True of False
How long should medical records be stored for an adult	Reords should be stored for 10 years from the date of the last entry
How long should medical records be stored for a minor	the medical record for the minor should be kept until the age of maturity plus the period of the statute
list safeguards to help prevent the loss of a medical record	when medical charts are removed chart location should be recorded in a journal Insert a file indicator in place of the chart designate one person to be responsible for filing place all charts in a back up system like microche
Improper disclosure of a patients medical records can have	civil and criminal penalties
when a medical record is subpoenaed these guidelines should be followed except	physician notification patient notification copy the entire chart verify the trial date verify all of the information in the subpoena
What purpose does a medical record serve	it serves as a document that gives a medical picture and record of the patient from life to death
give an example of personal information in a medical record	name dob ss# rx refill # # of children
Give examples of clinical information found in a medical record	diagnosis CPT/ICD ss# rx refill #
What are the acronyms for JCAHO
JCAHO and Medicare follow the same standard requirements for charting in the patient medical record; what is the requirement	timeliness
what is the correct way to make a correction in a paper chart
what is the correct way to make a correction in an EMR
Falsification of a medical record is grounds for criminal indictment	True of False
Federal reimbursement guidelines mandate that all med records should be completed within ___________ days following a patients discharge from the hospital
An original version of the patients medical record should be sent when it is subpoenaed	True or False

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