HIPAA
This rule requires staff to only access the information they need to do their job.
What is the Minimum Necessary Rule
If it wasn’t documented, it wasn’t this.
What is done
This is where you must submit a patient incident reported by a non‑staff member—and the timeframe in which it must be entered.
What is the Compliatric Incident Reporting System, and when is immediately?
This fundamental right ensures that every patient can understand their care, ask questions, and make informed decisions about their treatment.
What is the right to informed consent?
This federal law prohibits physicians from referring patients to entities with which they or their immediate family members have a financial relationship.
What is Stark Law (Physician Self-Referral)?
Discussing member information in hallways or public areas is considered this.
What is a HIPAA violation
Documentation must be completed within this timeframe.
What is 24 hours
This department is the primary resource for staff who need help completing or understanding an incident report.
What is the Quality & Compliance Department?
This patient right guarantees that individuals receive care in a safe setting and are treated with dignity, respect, and consideration at all times.
What is the right to respectful and safe care?
This department is the appropriate point of contact if you have concerns or questions about a potential HIPAA violation.
What is the Quality & Compliance Department?
These three types of safeguards protect PHI: administrative, physical, and this.
What are technical safeguards
This type of entry is used to correct an error while preserving the original note.
What is called Append!
This group of external authorities may review incident reports to ensure the organization meets safety, quality, and compliance standards.
Who are state and federal regulators, such as the Department of Health or accrediting bodies?
This patient right ensures individuals can review and obtain copies of their medical records and request corrections if they believe information is inaccurate or incomplete.
What is the right to access and amend their health information?
This is the process that ensures healthcare services are delivered safely, effectively, and in accordance with regulatory standards—and requires staff to follow policies, document accurately, and report concerns promptly.
What is maintaining quality and compliance in patient care?
This federal act governs how PHI must be protected and disclosed.
What is the Health Insurance Portability and Accountability Act
This type of improper billing occurs when a provider submits a claim to Medicare for a service that was never provided to a patient but was documented in the medical record.
What is False Claims Act?
This person is responsible for documenting a patient incident in the Compliatric Incident Reporting System.
Who is the staff member who witnessed or was informed of the incident?
This patient right ensures individuals can voice concerns or complaints about their care without fear of retaliation and expect a timely response from the organization.
What is the right to file a grievance?
This law imposes liability on individuals or organizations that knowingly submit, or cause the submission of, false or fraudulent claims for payment to the federal government.
What is the False Claims Act?
This requirement obligates staff to safeguard PHI in all forms and to report any unauthorized access, use, or disclosure to affected individuals and the Department of Health and Human Services.
What is the HIPAA Breach Notification Rule?
This is required before any patient record can be released, ensuring information is only shared with the correct person or entity.
What is a Release of Information form?
These types of events must be entered into the Compliatric Incident Reporting System, including errors, near‑misses, safety concerns, and any incident involving a patient.
What are all patient incident events?
This patient right ensures individuals can choose who may or may not receive information about their health, including family members, caregivers, or others involved in their care.
What is the right to privacy and confidentiality of their health information?
This law makes it illegal to knowingly offer, pay, solicit, or receive anything of value in exchange for referrals for services covered by federal healthcare programs.
What is the Anti‑Kickback Statute?