The complete medical record and electronic charting with 100% correct answers.

what is the most important record kept in the medical office medical record what are the uses of the medical record to provide means of communication for Financial purposes comma to serve as a legal document, to be used as an educational tool, to provide statistical data for research purposes what is the meaning for the acronym soap subjective objective, assessment, plan what type of information can be found in each part of soap subjective is what patient complains of, objective is info provided by health care professional, assessment is interpretation of subjective and objective findings and plan is providers plan for diagnosing and treating a patient what are the two types of charting systems Source oriented medical record and problem oriented medical record how is information placed in the medical record reverse chronological order what is HIPAA health insurance portability and accountability Act of 1996 what is HIPAA used to protect protects the handling of protected health information what are the penalties for violating HIPAA fines and jail time what is a flow sheet rocks found in the patient's chart for the system provider in monitoring specific repetitive information at one glance such as PT slash INR, glucose, blood pressure readings, diabetic, coumadin therapy, hypertension what is the required amount of time to keep medical records and how are they disposed of correctly 7 to 10 years for adults and 7 to 10 years after age of majority for Pediatrics medical records must be shredded what is considered the heart of the patient's medical record progress notes what type of information should be recorded within the record telephone encounters, procedures, treatments and other interactions that take place with the patient electronic medical records patient records in digital format electronic health records interoperability of electronic medical records, or ability to share medical records with other Healthcare facilities Source oriented medical record more traditional format used for recording data in the medical record period charts in which somr format is used for divided into specific sections including history and physical, progress notes, nursing medical assisting notes, laboratory and diagnostic testing problem oriented medical record contains four categories such as database, problem list, plan of action, progress notes who developed the pomr Lawrence weed who does the medical record belong to the practice or treating provider or Hospital the practice owns the physical part of the record, who owns the information stored within the chart the patient computer physician order entry application used by Healthcare Providers to enter patient care information advance directives legal documents such as a living will durable power of attorney and Health Care proxy that allow people to convey their decisions about end-of-life care ahead of time meaningful use set of Standards defined by CMS incentive programs that governs the use of ehrs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria business associate agreement document signed by all business partners to decide how Phi is to be handled commission that was the oldest and best-known of the six each are certifying agencies recognized by the onc as responsible for certifying electronic medical records CCHIT certification commission for healthcare information technology shingling method for filing live reports when reports are not the size of a standard piece of paper notice of privacy practices patient should receive a notice for how their personal medical information may be used problem list a record of specific problems that are identified from the patient history form, it should this be problems as they arise, each problem is numbered and she include the name of the problem or diagnosis minimum necessary requires that UD identify information Phi with all HIPAA identifiers are removed