C810 - Foundations of Data Management Revised Questions and Answers / Sure A +

What is a health record? - A complete, accurate, and current report of the medical history, condition, and treatment that a particular patient receives during an inpatient or outpatient encounter with a healthcare provider True or False? The health record may reflect one episode of care or an accumulation of all episodes of care (longitudinal record) - True What is included in demographic information collected at time of admission or registration for treatment? - - Name - Sex - Age - Insurance information - Emergency contacts What is included in clinical information? - - Patient's complaint - History of present illness - Medical history - Family history - Social history - Physician progress notes and orders - Reports of diagnostic tests - Surgery and other procedure reports - Nursing documentation - Final diagnosis(es) What is the rentention of the health record? - - The retention period refers to how long health records must be kept- The health record serves several purposes and must be retained to meet them - Such purposes include patient treatment, proof of services provided to justify reimbursement and evidence in legal proceedings - Federal and state statutes and regulations often determine retention periods Who owns the health record? - - The organization that creates and maintains the physical record is the legal custodian and is legally responsible for all aspects of it, including its integrity, security and completeness - Although the organization owns the record, patients have the right to access the record with exceptions noted in HIPAA What is express consent? - - Consent communicated through words, either written or spoken