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23 Cards in this Set
- Front
- Back
The Federal Rule of Evidence 803:
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governs the requirements for modification of the medical record & outlines strict criteria for any modification that may be deemed fraudulent
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HIPAA Privacy Final Rule
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Amendment of Protected Health Information:
1. that the record affected by the amendment be identified. 2. that individuals who may use the record amended by informed & in reasonable time. 3. that the covered entity of the original document be informed of the amendment |
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ASTM E31 Standards provides 3 methods for correcting and amending the record:
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1. Addendum signiture-on a NEW amended document by the individual who has corrected, amended, edited the original record
2. Modification signiture--on the original document by the individual who has generated the amended document. 3. Administrative (Error/Edit) Signiture--who is certifying that the document is invalid |
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HL7--addresses electronic concerns of creating audit trails and provides associated electronic messaging tags:
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1. creating an addendum--when the author dictates additional info that this info be transcribed in a NEW document w/ its own ID # that can be linked back to original.
2. correcting documents NOT yet made available-that the errors & corrections be made & a notification sent 3. in a document already available-that the original document be replaced with a new document with its own ID # and the original be marked obsolete, but be retained. 4. notification should be sent where a report has erroneously been sent, the wrong record retained but ID info be deleted. |
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the number of patient's rights under HIPAA:
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7
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Name the patient's rights under HIPAA:
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1. Right to notice of privacy practices.
2. Right to access PHI. 3. Right to request amendment. 4. Right to request alternative means of communicating PHI. 5. Right to request restrictions on PHI. 6. Right to an accounting. 7. Right to complain about privacy practices. |
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PHI
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protected health information
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PHR
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personal health record
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CE
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covered entity
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Name 3 things that providers must do under HIPAA:
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1. inform the patient of the extent of privacy protection (basically, their HIPAA rights);
2. they must obtain patient's signiture for any disclosures to 3rd parties; 3. must not disclose protected health information (PHI) other than certain exceptions |
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Define PHI:
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individually identifiable health information--demographics, past, present, or future physical or mental health conditions of the patient, payment information (from insurance providers, employers, etc, genetic information
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BA
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business associate
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Name several things you can do to protect a patient's health information:
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1. use encryption software
2. work in a secure environment to protect anyone from accessing computers or fax machines or from passersby 3. use monitor protectors |
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What is the civil penalty for HIPAA violations?
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up to $100
not to exceed $25,000/year |
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What is the criminal penalty for HIPAA violations?
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up to $250,000 and/or imprisonment for up to 10 years
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XML
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extensible markup language
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GRAMMAR:
2 or more words that sound the same and are spelled the same but have different meanings: |
homonyms
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GRAMMAR:
words that are spelled the same but pronounced differently: |
homographs
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GRAMMAR:
words that sound the same but are spelled differently: |
homophones
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GRAMMAR:
an "intrusive" word that sounds like the correct one, and is consistently used over & over: |
malapropism
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HEALTH IN THE WORKPLACE:
RSI |
repetitive stress injury
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HEALTH IN THE WORKPLACE:
CTD |
cumulative trauma disorder
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HEALTH IN THE WORKPLACE:
CTS |
carpal tunnel syndrome
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