Legislation
A federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
What is HIPAA
The medical record is the property of what entity?
What is the healthcare institution
A staff member discussing patients in the elevator is an example of what?
What is a breach of confidentiality
Willful disregard of a subpoena or court order is considered
Contempt of Court
EHR
What is Electronic Health Record
Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of what entity?
What is Office for Civil Rights
Significant findings during hopspitalization are found on what document in the EHR
What is the discharge summary
A legal and ethical concept that requires healthcare providers to protect health records and other personal and private information from unauthorized use or disclosure. For example, any information a patient shares with a physician will be kept private between the patient and physician.
What is Confidentiality
In addition to supplying the record, the person who possesses the record could be compelled to deliver it at a certain time and place if the request is accompanied by this.
What is Subpona
What is Minimum Data Set
COBRA stands for?
What is the Consolidated Omnibus Budget Reconciliation Act?
A medical entry that must be documented for every patient no more than 30 days before or 24 hours after admission to the hospital. It contains pertinent information about the patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems
What is a history and physical (H&P)
Name, Date of Birth, Address, Next of Kin, SSN are examples
What is Protected Health Information
Can be defined as those devices or tools used by one side to obtain facts and information about the case.
What is Discovery
HIPAA
What is the Health Insurance Portability and Accountability Act of 1996
Federal regulations that hospitals must comply with that establish standards of care (Hint: To qualify for Medicare reimbursement)
What is Medicare Conditions of Participation
Includes a microscopic description of tissue excised during surgery
What is a pathology report
How covered entities may use and disclose PHI. Patient’s rights regarding the covered entities’ uses and disclosures. Covered entities’ obligations for protecting the patient’s PHI.
What is Notice of Privacy Practices
The minimum length of time for retaining original medical records is primarily governed by
What is state law
UHDDS
What is Uniform Hospital Discharge Data Set
The American Recovery and Reinvestment Act was signed into law in 2009, and included significant funding for what technology type
What is Health Information Technology
This documentation would be found in- “With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line which was taped to skin and used for administration of drugs during resuscitation.”
What is operative report
A metadata repository of data elements used in an information technology system used in healthcare. Includes specific data fields and the security levels applicable to that field. (Hint pg. 145 Fahrenholz)
What is a data dictionary
The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility (HINT: S&G pg 103 &209)
What is CARF manual- Commission on Accreditation of Rehabilitation Facilities
SOAP
What is Subjective, objective, assessment, plan (SOAP)