Legislation
Components of the Medical Record
Privacy and Security
Healthcare and the Law
Medical Record Abbreviations
100

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

100

The medical record is the property of what entity?

What is the healthcare institution

100


A staff member discussing patients in the elevator is an example of what?

  

What is a breach of confidentiality

100

Willful disregard of a subpoena or court order is considered

Contempt of Court

100

EHR

What is Electronic Health Record

200

Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of what entity?

What is Office for Civil Rights

200

Significant findings during hopspitalization are found on what document in the EHR

What is the discharge summary

200

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

200

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

200
MDS

What is Minimum Data Set

300

COBRA stands for?

What is the Consolidated Omnibus Budget Reconciliation Act?

300

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)

300

Name, Date of Birth, Address, Next of Kin, SSN are examples

What is Protected Health Information

300

Can be defined as those devices or tools used by one side to obtain facts and information about the case.

What is Discovery

300

HIPAA

What is the Health Insurance Portability and Accountability Act of 1996

400

Federal regulations that hospitals must comply with that establish standards of care (Hint: To qualify for Medicare reimbursement)

What is Medicare Conditions of Participation

400

Includes a microscopic description of tissue excised during surgery

What is a pathology report 

400

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 

400

The minimum length of time for retaining original medical records is primarily governed by

What is state law 

400

UHDDS

What is Uniform Hospital Discharge Data Set

500

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 

500

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

500

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

500

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

500

SOAP

What is Subjective, objective, assessment, plan (SOAP)