Business Writing and EHR Final Review

heyguysitsclaire's version from 2016-04-06 22:07

Section 1

Question Answer
HIPAAS laws regarding medical recordsThe Privacy Rule gives you, with few exceptions, the right to inspect, review, and receive a copy of your medical records and billing records that are held by health plans and health care providers covered by the Privacy Rule.
EHR easily shared with other health care providers such as hospitals, labs and other physicians
EMRrestricted only to use in one specific office
Meaningful UseThe practice of physicians and hospitals using certified EMR technology in a meaningful manner as an incentive of a program established by congressional legislation
Rule for abbreviation use in medical records and business writing Only use ones that have been approved by medical office
What are templates, spell check, grammar check and thesaurus used forTo make sure the letter or form is accurate and professional
What is a flow sheet?designed to limit the need for long hand written care notes by allowing info to be recorded in either graphic or table form
Parts of a memoHeading, Date, To, From, Subject, Body, Copy
Agendabriefly outline the topics to be discussed at a meeting
Minutesoutline the actions of the members of a group
Covered EntityHealth insurance plans, health care clearinghouses, health care providers who use electronic billing, funds transfers, EHRs
HITECH actto provide support and financial incentives for providers to use electronic health records
POMRlists each problem of the patient, usually at the beginning of the folder and references each problem with a number throughout the folder
SOMRorganizes the information according to patient care department that provided the care, or who provided the care
How to make sure that your electronic system is secureKeep cpu backup storage in a safe place, use passwords with characters other than letters and encrypt, change codes and passwords every 30 days, prepare back up plan in case CPU is down, make sure cpus aren't facing patients, keep fax machines and printers in a private place, etc...
Who do you have to notify if a breach in security occurs?Secretary of the department of health and human services
What is an EHR capable of?Point of care charting, improved documentation, data collection from multiple sources, medication management, assistance with clinical decision making, improved communication, support for administrative/financial/operational functions
Sections of a medical recordCC, present illness, family and personal history, review of symptoms, progress notes, radiographic reports, laboratory results, consultation reports, medical administration, diagnosis or medical impression, physicians and/or medical assistants ID and signiture, documented advance directives, all correspondence pertaining to the patient
Different mailing optionsExpress, priority, first class, standard
Chronological orderplacing in order of time; usually the most recent is placed foremost
Functional orderplacing in smaller groups based on topic
Watermarka faint design made in some paper during manufacture, which is visible when held against the light and typically identifies the maker.
Vital signs that should be put into EHRHeight, Weight, BMI, BP, Respiratory rate, Heart rate
Second sheeta sheet of blank stationery, used in a letter as the second and following pages to a sheet having a letterhead

Section 2