Confidentiality in Allied Health Final Exam
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Clinical Uses of Medical Records - ✔ANASWER✔-Medical records
serve as a repository of information that caregivers can use in diagnosing
and treating medical problems.
Medical Record - ✔ANASWER✔-A document that includes a patient's
history, condition, diagnostic and therapeutic treatment, and the results
of treatment.
Nonclinical Uses of Medical Records - ✔ANASWER✔-Medical records
include information that may relate to third parties who have a financial
interest in a patient's medical condition.
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Statutory/Regulatory Requirements - ✔ANASWER✔-Statutes and
regulations pertaining to medical care and payment may require the
creation and maintenance of certain records.
Accrediting Standards - ✔ANASWER✔-Organizations such as The
Joint Commission (TJC) have accrediting standards that address medical
records.
Patient History - ✔ANASWER✔-Information about a patient's past
health issues and treatments that is included in a medical record.
Diagnostic Treatment - ✔ANASWER✔-The process of identifying a
disease or condition and determining the appropriate treatment.
Therapeutic Treatment - ✔ANASWER✔-The management and care of a
patient to combat a disease or condition.
Legal Disputes - ✔ANASWER✔-Situations in which medical records
can serve as evidence regarding a patient's condition or the actions of
medical care providers.
Third Parties - ✔ANASWER✔-Entities such as insurance companies
and employers that may have a financial interest in a patient's medical
condition.
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Patient Confidentiality - ✔ANASWER✔-The ethical principle that a
patient's personal health information is private and should not be
disclosed without consent.
Medical Coding - ✔ANASWER✔-The process of translating healthcare
diagnoses, procedures, medical services, and equipment into universal
medical alphanumeric codes.
Quality Monitoring - ✔ANASWER✔-The process by which medical
institutions use medical records to assess and improve the quality of care
provided.
Release of Medical Records - ✔ANASWER✔-The process by which a
patient authorizes the transfer of their medical information from one
healthcare provider to another.
Medicare Requirements - ✔ANASWER✔-Specific information that
must be included in medical records for participation in Medicare.
The Joint Commission (TJC) - ✔ANASWER✔-An organization that
sets standards for and accredits healthcare organizations and programs in
the United States.
Patient Information - ✔ANASWER✔-Details about a patient that may
be personal, medical, or financial in nature included in a medical record.
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Scientific Studies - ✔ANASWER✔-Research that may utilize medical
records for analysis and data collection.
Commercial Use of Information - ✔ANASWER✔-The potential use of
patient information contained in medical records for business purposes.
Malpractice Suits - ✔ANASWER✔-Legal cases in which medical
records can serve as evidence regarding the quality of care provided to a
patient.
Office Policies - ✔ANASWER✔-Internal guidelines that govern the
creation and maintenance of medical records within a healthcare facility.
American Academy of Professional Coders (AAPC) - ✔ANASWER✔-
An organization that provides ethical and professional standards for
employees in health information management.
American Health Information Management Association (AHIMA) -
✔ANASWER✔-An organization that provides ethical and professional
standards for employees in health information management.
Institutional Standards - ✔ANASWER✔-Standards and procedures that
individual institutions apply to medical records, in addition to legal
requirements.