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27 Cards in this Set
- Front
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A collection of data recorded when a patient seeks medical treatment |
Medical Record |
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5 purposes served by a patient's medical record |
1.)Required by licensing authorities and provide a format for tracking, documenting, and maintaining a patient's communication data, both inside and outside a health care facility 2.)Provide documentation of a patient's continuing health care, from birth to death 3.)Serve as legal documents in lawsuits 4.)Provide a foundation for managing a patient's health care 5.)Provide clinical data for education, research, statistical tracking, and assessing the quality of health care |
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As the person responsible for charting in a medical office, would you record a patient's statement that she often feels "woozy" and thinks she has "dropsy"? Why or why not? |
Yes, such remarks are useful for the physician as he/she questions the patient about symptoms and medical history. |
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If a reconstructive surgeon wants to publish "before" and "after" photographs of patients in a brochure left in the waiting room for distribution to prospective patients, what must she do? |
She must obtain the patients permission in writing |
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If a patient makes critical remarks to you, a medical assistant, about your physician/employer, would you record the remarks in the patient's medical record? why or why not? |
Yes, it is important to document any patient complaints, and it is important for the attending physician to know the patients concern |
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You are charting after a patient's office visit and you are interrupted by a telephone call. The interruption causes you to incorrectly record results of the patient's blood tests. When you discover your mistake, can you correct it? If so, how? |
Yes, you can correct the records by drawing a line through the incorrect entry and writing the correct information above; you should also note, either in the margin or through an attachment, that you were interrupted by a telephone call and entered the wrong information |
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Briefly explain how corrections made to an electronic medical record differ from corrections made to a paper record |
Electronic-can attach new page with corrections |
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How long should medical records be retained? |
From 2 to 7 years, however records of minors may need to be kept 7 years after they reach the age of 21. The retention is state specific.
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Who owns a patient's medical record? |
the facility that created the records owns them, but the patient owns the information they contain |
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A principle under which a physician can exercise judgment as to whether to show patients who are being treated for mental or emotional conditions their records. |
doctrine of professional discretion |
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Are you entitled to a copy of your own medical records on request? Explain your answer |
Yes, you are entitled to your own medical record with the appropriate written release. However, a practitioner always has the right to release specific information if it is deemed detrimental to your care |
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If medical records are lost prior to the filing of a medical malpractice lawsuit where the records are necessary, what might result? |
The defendant in the lawsuit would have no record and thus in all likelihood be liable |
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Name three reasons a medical office might be requested to release a patient's medical records? |
insurance claims, lawsuits, transfer by patient to another physician |
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A patient's written consent to release records can be waived |
lawsuits; if subpoenaed in court
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What is needed before the medical office can send a patient's medical record to the insurer? |
written permission from the patient
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If an insurance company submits a request for medical records pertaining to an enrolled patient's outpatient foot surgery and you are responsible for sending the records, should you send the patient's entire file to be on the safe side? why or why not? |
no, you should send just the records requested. Additional information is confidential
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As the person who reviews requests for patients' medical records, do you need to know the purpose for which the data will be used? Explain your answer |
yes, you need this information for office or hospital records, and to be sure the request is legitimate and will not violate patient privacy |
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Who may give informed consent |
adults of sound mind |
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Who may not give informed consent |
minors (except emancipated and mature minors), mentally incompetent, and those who speak a foreign language and need an interpreter
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Must consent to perform routine medical care, such as a physical examination, always be in writing? Explain your answer |
no, consent is implied by the patient's making an appointment to see the physician
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In which health care situations is implied consent not sufficient |
when either inpatient or outpatient surgery is performed, for HIV testing, for abortions (consult state law), when treating minors
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What consequences generally ensue if a legally competent adult is treated without consent and an adverse event occurs? |
a physician is liable for battery- a charge separate from any negligence claim file |
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How does an electronic medical record differ from one kept on paper? |
the EHR provides a way to store records electronically and to format all records in a similar manner. Paper records can be lost, misfiled, or easily destroyed |
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The application of information processing involving both computer hardware and software that deals with the storage , retrieval, sharing and use of health care information, data and knowledge for communication and decision-making |
Health information technology |
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Name two measures the federal government has taken to speed the adoption of electronic medical records |
HIPAA, Execute Orders, Health Information Standards, Patient Protection and Affordable Care Act |
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According to the federal government, what are two ways the use of electronic records might improve patient care |
improve health care quality; prevent medical errors; reduce health care costs; increase administrative efficiency; decrease paperwork; expand access to affordable care |
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You are photocopying a patient's medical record and an employee from the clinic's accounting department is reading over your shoulder while he waits to use the copier. What should you do? |
Remind the person that medical records are confidential, and ask that he step back until you have finished photocopying the records |
