Medical Records Maintenance
where medical records are stored
What is a locked, fireproof filing cabinet?
Unauthorized use or disclosure of PHI, unless a risk assessment shows low harm (e.g., encrypted data).
What is a breach?
Within the electronic medical records, this feature reduces errors, speeds up care, improves team coordination and makes medication and lab orders safer for patients
What is the computer provider order entry?
Patient registration form, HIPAA Notice of Privacy Practices form, HIPAA release of information form
What forms should be included in a new medical record?
the most common filing system in medical facilities, filed according to the sequence of letters in the alphabet
What is alphabetical filing?
Duplicates of studies, reports, and forms, Hospital studies over three years old that show normal findings, Insurance forms over seven years old
What are some items that can be deleted from the medical record?
use or share only the least amount of PHI needed
What is the minimum necessary standard?
an electronic collection of the patient's health history, maintained by the patient
What is the personal health record?
medical records that are sorted by the same-type
What is the source oriented medical record?
a filing system where each patient's medical records is assigned an identification number and filed in order
What is numerical filing?
an inspection and verification of a facility’s records and supporting documents.
What is an audit?
wounds received during a crime, evidence of child or elder abuse, communicable disease leading to public concern
What is HIPAA exceptions?
this feature allows different healthcare providers to access and share patient information, improving coordination and continuity of care
What is interoperability?
Completed by the radiologist and documents the results of diagnostic procedures, such as X-Rays, CT scans, MRS scans or nuclear medicine procedures
What is the radiology report?
What is the location of the primary file?
full name and date of birth
What two patient identifiers must be used when documenting in the medical record?
provides guidelines on the protection of electronic health information
What is the security rule?
Index this: J.W. Hewitt Tax Attorney
Hewitt, J.W. Tax Attorney
this allows patients to review health information, schedule appointments, request prescription refills, and message providers directly
What is the patient portal?
In the numerical fling system, this is the alphabetical index of patient names and identification numbers
What is the master patient index?
a law that sets the maximum time period within which legal proceedings must be initiated for a particular offense or civil claim.
What is the statue of limitations?
The length of time a facility has to provide records to patients once they request them
Index this name: Carla Maria De La Cruz
Delacruz, Carla Maria
the medical facility owns ________, where the patient owns the _________
What is the physical medical record and the contents of the medical record?
how you would file names with Jr., Sr., Dr. after their name
What is alphabetical order?