What must each patient record include? *10 items* - -patient demographic/registration information
-medical history
-physical exam
-clinical data and observation
-physician orders
-results from care
-discharge summary
-patient instructions
-consultations
-acknowledgement, authorization, and consent forms
What does EHR have to do with CCD? - Sending and receiving CCDs between facilities.
What are 4 instances you can release PHI? - -reimbursement
-patient/legal representative requests this
-Health and Human services is investigating
-mandatory reporting
What is adamant? - Persistent.
Is the change from old systems of record keeping disruptive/difficult? - Yes.
What are ways to back up data? *5 ways* - -redundancy
-off-site location
, -stay up to date
-practice restoring data and checking integrity
-consult with vendor or IT and HIM departments
How much information do you release of PHI? - Minimum necessary standard.
What is a prominent person? - Someone who's well-known for being an expert on a certain topic.
What is the value of an audit? - Way to make sure facility is following the rules.
What kinds of information does an EHR specialist have to keep private? - Any personal information
about a patient.
(ex: financial, diagnoses, medications..)
What's stage 1 meaningful use? - Measure of how many patients filled out advance directives.
What 2 departments get the data (in facility)? - HIM and IT.
Who reviews audit trails? - EHR specialist.
What happens when there's a breach in security? Who informs the victim(s) and public? - Provider (staff
within facility) informs victim and secretary of department of Health and Human Services and media.
In what cases can PHI be released without authorization? *8 things* - -support treatment
-reimbursement
-support daily business operations
-subpoenas
-legitimate law enforcement inquiries
-cases of suspected abuse and/or neglect
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