Med Records
Two ways patient charts can be kept
Paper and Electronic Medical Records
What does OSHA mean?
Occupational Safety and Health Administration
Three types of communication
Verbal, Non-verbal, written
What is an out guide?
A space holder for where a chart goes when it is pulled for a specific purpose.
This group is in charge of the ICD-10 codes
World Health Organization (WHO)
What do you need in order to give copies of a patient's chart to someone other than the patient?
Authorization to release records
What is an SDS?
Safety Data Sheet
This is also known as a bill and lists products or services rendered.
Invoice
What are the three main types of filing systems?
Alphabetic, Chronological, Numeric
What is "X" used for in an ICD code?
What is PHI?
Personal Health Information
What are two things you need for Fire Safety?
Fire extinguisher and escape plan
The greeting of a formal business letter
Salutation
This is the way patient records are created, filed, and maintained.
Records management system
When two diagnoses are in one code this is a _____?
Combination Code
How long do you have to keep records of a deceased patient in Texas?
7 years
This outlines employees responsibilities needed to reduce panic in case of an emergencies and reduces likelihood of severe bodily injury
Emergency Action Plan
Are emails considered to be secure forms of communication according to HIPAA?
No
This tells you how long to keep each type of chart after inactivity or being closed.
Retention Schedule
These are typically indicated by starting with the letter "Z".
Health Status Codes
What is the alternative method of charting that begins with a chief complaint?
CHEDDAR
Cheif Complaint, History, Evaluation, Details, Drug and dosage, Assessment, Return visit or Referral
Name 5 things found on an SDS
Identification, Hazard Identification, Composition or Ingredients, First-Aid Ingredients, Fire-Fighting Measures, Accidental Release Measures, Handling and Storage, Exposure Controls/Personal Protections, Physical and Chemical Properties, Stability andand Reactivity, Toxicological Information
According to HIPAA, what is considered electronic media?
transmissions physically moved from one location to another using magnetic tape, disk, compact disk, portable computer drive
This contains patient names and their medical record number.
Master Patient List
How many chapters or categories of ICD-10 codes are there?
21