EHR
What is included in EHR
Practice management capabilities for patient scheduling and generated reports for research and quality control.
What part of SOAP contains what the provider observes, can see, or measure?
Objective Data
What do HIPAA security rules address?
The national standards used to protect electronic protected health information.
What is the oldest method for filing?
Alphabetic Filing
What is POMR?
Problem-oriented Medical record
What are the two types of health records
Paper and Electronic
What part of SOAP includes the provider's suggested treatment?
Plan
Under HIPAA, what are the patients rights?
The patient has the right to examine and obtain a copy of their health record. They can also request corrections to be made.
What records are rarely used but kept for reference?
Inactive
What does NPP stand for?
Notice of privacy practices
What are two benefits of paper records
No downtime and they are always available for use.
What part of SOAP includes what the patient says?
Subjective Data
What is the main purpose of the HIPAA privacy rule?
To define and limit when a person's information can be used or disclosed.
How long are closed records typically retained for?
7 - 10 years
What does ROS stand for?
Review of Systems
Where are paper records kept?
Records should be kept in a locked room or locked filing cabinet.
Which part of SOAP includes what the provider thinks it is?
Assessment
What all does the HIPAA Security Rule cover?
Cocers records that are created, used, recieved and maintained by covered entities.
What are the 4 steps used to make a correction on a paper health record?
Draw a single line through it
Put the correction above it
Write error
Add the date and your signature
What does SOMR stand for?
Source-oriented Medical record (The traditional patient record)
Who owns the (EHR) Electronic Health record?
The provider of the health facility owns the physical health record.
Which part of SOAP adds education and response
SOAPER
What are covered entities?
Anyone who transmits electronic health records. (Health providers, health insurance plans, and claims clearinghouses that transmit PHI electronically.
This is act of separate inactive records from active records?
Purging
What does AHIMA stand for
American Health Information Management Association