Which Of The Following Is True About Hipaa

-PHI (protected health information) -The Privacy Rule -The Security Rule -Possible consequences of not following HIPAA regulations

-B, it protects patients -HIPAA Privacy Rule gives patient-specific rights related to medical records -HIPAA Security Rule requires administrative, physical, and technical safeguards are developed by facilities to protect patient information

-Notes and documents that health care professionals add to medical record -Collection of all documents filed together -Form complete chronological health history -Organized per facility policy -All health care workers responsible to maintain records per facility policy -Chronological or source-oriented

-Recording of observations and information

-Contributes to good patient care -Provides legal protection -Helps ensure regulatory compliance -Improves cost control -Decreases denials from insurance companies

-Complete with all requested information -Concise and factual -Properly identified -Legible -Correct spelling, terminology, punctuation, and grammar -Clearly and objectively expressed -Findings not duplicated -Approved abbreviations listed in facility's policy used -Time and date given for all entries

-Signed by proper person -Completed without leaving empty lines -Always charted after giving medication or performing procedure, not in advance -Written with black or blue ink

-Draw single line through error -Write in correct information -Note error per facility policy -Date and initial correction -Correct immediately on computer -If discovered later, correct as above

A. Charting -Charting: Recording of observations and information about patients -Medical documentation: Notes and documents that health care professionals add to medical record

-History and physical (H&P) -Physician's orders -Diagnostic tests -Admissions -Surgical procedures -Graphics -Flow sheets -Medication record -Progress notes -Reminder: -Verify correct form in chart by ensuring patient's name on each document -Each section chronological -Thinning a chart -Security of files

C. Flow sheets -Flow sheets: Forms for specialty needs -Progress notes: Written chronological statements about patient's care -Graphics: Graphed forms for vital signs

-Primary tool: Recording, communicating and coordinating care of patient May include the following: -Observations -Treatments -Patient response

-Problem-oriented charting -Narrative charting -Charting by exception -Computerized

-True -Chief complaint: reason patient seeks medical care

-EHR systems can go far beyond the core charting -Coordination tools -Information -Safety tools -Scanned documents -Can only communicate within same health care system

-Recommended for patients -Due to mobility of individuals -Frequent changes in providers -Frequent changes in insurance coverage -Assists patient to recall events and dates -Prevents long delays in requesting information -Types of information to include -Demographics, such as name, address, contact information, etc -Emergency contacts -Name, specialty and contact information of previous providers -Insurance provider(s)

-Medical directives, living will, organ donation, etc. -General medical information: height, weight, blood type, vital signs, etc. -Allergies and drug sensitivities -Current conditions and date of diagnosis -Previous surgeries, including date and results

-Medications (prescription and nonprescription) -Immunizations and when last received -Any relevant health care visits, such as hospitalizations, other specialists or therapists -Pregnancies -Medical devices