I am...Medical Record
Examination of the body (Clinical chemistry report)
Lab reports
What does HIPPA stand for?
Health Insurance Portability and Accountability Act
The reason why I'm visiting
Chief Complaint (CC)
"I'm busy, Molly (another MOA) can fill this out?"
You cannot let others to fill your document
Admin record keeping docs (e.g. Patient Registration Record)
Medical office admin records
What is Notice of Privacy Practices (NPP)?
Explains to paitents how their protected health information (PHI) is used and protected
In the Progress Notes, this is a full description of a patient's current illness
Present illness (PI)
MOA:"I'll fill out the document tomorrow"
Document immediately after performing a procedure
Legal document required to perform procedures or to release info in the paitent medical record
Consent
In the protected health information (PHI) what are 3 an example of identification
Name
Address
Social Security Number
Photo
Telephone
Email Address
MOA: "Have you ever had the Chickenpox or Mumps before?" Which part am I?
Past History
Patient: My name is Sungwon (Song-won), and I have a history of epilepsy
MOA writes down: Patient's name SANGWUN, hitroy of rash
Documentation information accurately, incorrect spelling
Assist the patients' provider in reviewing patient's ____visits
Hospital Documents
List 2 things falsifying medical records can lead to?
Loss of job
Loss of license/certification
Legal charges (fines or jail time)
Lawsuits
Patient harm
Professional discipline
MOA: "Does your moether or father have a history of High Blood Pressure?"
Family History
She had blood samples taken, the MOA listed the time and date but forgot to include ______
where it was sent & that date
Type of procedures performed to assits in dianosis tic, mnamagement or treatment in patient's condition
diagnostic procedure
What are some situations where you can disclose PHI without consent
Medical Treatment, Payments, Health Care Operations, Legally mandated Reports
MOA: "Do you excercise a lot?"
Social History
The previous doctor wrote down she has this condition and that's it. What am I missing here?
Date, time, signatures, patients fill out the form