Chapter 38: The Medical Record Questions and Answers well Explained Latest 2024/2025 Update 100% Correct.
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Course
Chapter 38: The Medical Record
Institution
Chapter 38: The Medical Record
What does the term "meaningful use" refer to? - "Meaningful use" refers to the CMS incentive
program that requires providers and institutions to prove that they are using the EMR in a meaningful
way. For each stage of the program, there are additional requirements in order to receive financial
i...
Chapter 38: The Medical Record
What does the term "meaningful use" refer to? - "Meaningful use" refers to the CMS incentive
program that requires providers and institutions to prove that they are using the EMR in a meaningful
way. For each stage of the program, there are additional requirements in order to receive financial
incentive payments for Medicare patients.
What is a Notice of Privacy Practices (NPP)? - Written document provided to patients that explains
how their protected health information will be used and safeguarded by the medical office.
What is the meaning of the acronym HIPAA? - Health Insurance Portability and Accountability Act.
What is the purpose of the HIPAA privacy rule? - To provide patients with more control over the
use and disclosure of their health information.
Who must comply with HIPAA? - All health care providers, health plans, and health care
clearinghouses (e.g., billing services) that use, store, maintain, or transmit health information.
List examples of when HIPAA does not require written consent for the use or disclosure of a patient's
health information in the following categories:
a. Treatment:
b. Payment:
c. Health care operations: - a. Treatment: Patient referral to a specialist, emergency care at a
hospital, performance of tests on a patient by a laboratory.
b. Payment: Determination of eligibility for insurance benefits, review of services provided for medical
necessity, utilization review activities.
c. Health care operations: Quality assessment activities, contacting of patients with information about
care or treatment, employee review activities, training of health care students.
, What are the two most common types of medical records? - Paper-based medical records and
electronic medical records are the two most common types of medical records.
Briefly describe how the Health Information Technology for Economic and Clinical Health (ITECH) Act has
accelerated the adoption of electronic health records. - The HITECH Act includes financial
incentive payments to health care facilities and providers who adopt electronic medical records.
List three functions of the medical record. - The physician uses the information in the medical
record as a basis for making decisions regarding the patient's care and treatment; it serves to document
the results of treatment and the patient's progress and provides an efficient and effective method by
which information can be communicated to authorized personnel in the medical office; it also serves as a
legal document.
Describe each of the following medical record formats: source-oriented record, problem-oriented record
and electronic health record? - Source-oriented record- A medical record arranged by the source
of each paper document (e.g. laboratory reports, hospital reports, diagnostic reports, etc.
Problem-oriented record - a medical record arranged by patient problems. Progress notes are in SOAP
format (subjective, objective, assessment, plan).
Electronic health record - a medical record maintained using a computerized system where patient
information is accessed from a database section, with major divisions into billing, clinical and scheduling
sections. Within the clinical section there are tables that allow the clinician to link to various types of
clinical information.
What is reverse chronological order? - Reverse chronological order files notes and reports with
the most recent on top.
List and describe the four parts of a POR. - Database: Collection of subjective and objective data
used to compile a patient list.
Problem list: List of patient conditions that require observation, diagnosis, management, or patient
education.
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