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A medical record ordered by the court to be available during a malpractice case is
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Medical record management requires
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ALH 106 FINAL
ALH 106 FINAL TEST/STUDY GUIDE chpt 9
| 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 |
Created by:
SBGrandRapids