HM101 Final Exam Mary Lester 1.

Privacy as concerned to patient mean that patient can be assured that their information is secure and given out to only those that they choose to have it Privacy helps the health care provider by adhering to the guidelines they can prevent law suits, due to lost records, misuse of records but also accurate records can help them in a legal situation. 2. Consistency in data quality is the highest priority, if there isnt consistency in date it is harder to find information that might be very vital to patient care. Documentation consistency means that a patient will get the proper treatment. Lets say a doctor needs to order and MRI but documentation does not support the need for an MRI, the insurance company may deny the MRI and a tumor or condition may go undetected. Health care professional need to be totally aware of what and who is documenting. 3. Health care facilities may use this as a back ground check when hiring a practitioner because it shows malpractice suits against a practitioner as well as their credentials. If a hospital hires and doesnt use this data base it could put patients at risk. Has the practitioner acted unprofessionally I other setting, has he/she continued their education, which helps keep their credentials? Can they participate with Medicare and Medicaid? What happened and do they want to associate themselves with that practitioner. 4. MIB collects information about a person history and lifestyle when applying for insurance, I believe it both helps and hurts. It helps because coverage to someone with no problems or abuses is easier and more affordable. The hurt comes when someone has completely changed heir life, lost weigh, exercises, eats right but has a pas history of hypertension or high cholesterol, their coverage is going to be different and not so affordable. I think because this medical and non medical information is allowed to influence insurance agents about what type of insurance is a major flaw in health care

5. Quality of health care is difficult to define because though the standards are set different software uses this information in different ways. I believe that comprehensiveness is vague and not entirely objective because All the date you need and no more means different things to different people. I may feel that a person comment about his deceased mother may mean he misses her. A physiologist might take it that his grief is severe and much more therapy is needed. I may leave the comment out of the date because it isnt needed for his care from my doctor. Relevancy is the other standard I believe is vague and not entirely objective. Who am I being a nurse or doctor to decide what is relevant or not. A patient served in Afghanistan tells the nurse he is sad. But no where is it documented that he served in the war. The doctor doesnt see this as a problem because a lot of people are sad, and the patient seems perfectly normal to the doctor in conversation. Had the doctor known the patient was a war veteran would he have explored the sadness further? 6. Specialized software. They may not need it but I am very sure they will need it in the end. Better to buy once and grow into it. 7. Specialized software 8. Specialized software. 9. This is considered primary information, because it is coming from the facility not outside. I would run a report via the computer system that shows all dates of service for the ear 2000, by patient name. If computer system was not available I would go to all paper data for that year in storage and compile a report from that. 10. Absolutely not HIPAA is very clear and I would not risk my job for anyone. I would advise my best friend to speak to another doctor, have him/her evaluate the situation and then make a decision based on his/her opinion. I am not a doctor number one and could not make a decision and number two it is totally against the law with fines and jail time and not worth it even if it means losing a friendship. 11. HIPAA regulation do not allow this unless one nurse is giving report to the next on coming nurse, but then it wouldnt be done in the cafeteria. If the nurse had concerns about the medical condition of a patient they should be expressed to her supervisor or the doctor. What if my mom was a patient and the next thing I see after hearing that is that nurse coming out o my moms room? What they discussed and I overheard, could that be my mom they were talking about?

12. A patient has come in to see the doctor for headaches. She tells the doctor she had throat cancer. The cancer registry would have recorded information about her cancer, about other people who have had this cancer. It lists research and statistical information, such as specific hereditary characteristics, environmental agents that could affect this cancer. They show physician record, health and pathology report, risk factors and treatment follow-ups. This registry information could lead the doctor to further testing for additional cancer. 13. No computer system, easy to assign numbers 14. Records are stored in different locations 15. One location 16. Need computer, paper files become too thick 17. No computer system, numbers are easy and all records are in one location 18. Cross reference notes remain, however paper records become very thick. 19. I would recommend the serial unit, because though paper records can become thick, you can always make a records only chart and have an office notes, procedure chart all in the same place. No name mix ups or family mix ups each person has their own record with old visits all together 20. Specialized software that will meet my needs for not only records but patient list and demographics. One that will also sort scanned information from outside (secondary) sources such as pre surgical labs, ex-rays or referring information from another doctor. 21. Automated database. Easier to store more information though manual is less expensive it also takes up more storage space and paper. In the long run all those paper charts have to be stored 22. Automated again, my filing space is limited and computer storage is larger 23. Straight numeric filing. It is easy to retrieve records. Requires less training. Anyone can count and numbers are more secure than names.

24. Serial unit system, because no matter which surgeon saw the patient all the records would be in the same place and accessible by all.

25. 1. 990012 2. 990112 3. 769012 26. 1. 990012 2. 990112 3. 901234

4. 901234 5. 805672 6. 815672 4. 805672 5. 815672 6. 769012

27. Finding the department that store particular patent records moving around to different departments after admit. Providers dont have access to all departments that might have the records. It is almost impossible for an HIM department to ensure that the records are complete. 28. This question is too broad for a direct perfect answer. IF the doctor disclosed to the patient what he was doing totally with the pictures then yes under the HIPAA it is legal to do so. However, if the patient believes that only his records get a copy of the pictures then it is not legal and this surgeon is opening up his self to a major HIPAA violation. This physician should also make sure that the patient signs a release to all the intentions of the physician and the pictures. 29. All medical records belong in the patient files. I would suggest that everyone split the pile of records and pull files. Get them filed in the proper order and file. Every patient-has a right to complete and accurate medical records. There fore it is a violation to have them out of the files and throwing them away is total mis guided way to clean up. 30. I believe the impact is major in that medical transcriptions are no longer needed with EMR. Doctors, Nurses, PA, and NP all enter in the information directly into the system leaving no dictation necessary. I have a very good friend who lost her job of 8 years when the doctors office she worked at went electronic. The doctor enters the information while the patient is in the room and nothing more is needed. 31. First verify that it is the insurance company with a call back number and reference number, employee number of the caller. Make sure payment was not sent for the claim in question. But most important make sure that the patient has signed an insurance record release of information then fax the record.

32. If there is not release of information signed for insurance, listing husband, wife, mother, brother, sister, aunt, uncle regardless of the relationship if the name is not specifically mentioned on the release of information they do not get it! Even another doctor or lawyer, with out the release of information specific to that person the records do not leave my office. 33. Cambridge Putts its heart first This research uses children from the Centre 33 who range from 8-18, who in some way support family members with long term illnesses, disabilities be it mental, drug or alcohol related skills to cope. The help them understand the disease and give them skills to reduce obesity and heart disease. They teach them to golf; give them heart healthy tips on eating and lifestyle changes. The center gives free counseling for young people under 26, as well as different areas that children may need. They are really working with children of disadvantaged adults to help the future generation be healthier and more aware. I reached out to the center to ask about HIPAA and was told they follow all the guidelines of a full fledge counseling center. The Putts its heart first program is just a group that teaches the children about heart health and healthy living for your heart. 34. ABCnews.go.com/m/story?id9977262. Walgreens hired a teenager as a pharmacy technician. She admitted typing in 10mg of heparin instead of 1mg. This caused the patient to have a massive crippling stroke, which intern caused her to have to stop her breast cancer treatment. She died as a result. I believe the profession should have higher standards and training for pharmacy technicians. They should be board certified. I believe just like a doctor, other health professional should have continuing education and standards. The health care changes need to include pharmacy technician. I am sure the tech is my story lost her job, but the company who hired her is getting sued for billions. What will she face? The article didnt say. As a CPC I am liable and could face fines and jail for fraud and abuse. Maybe if more companies, tech and pharmacists pay stiffer fines they will be a lot more reliable. I am not sure anything new can help because the most I say in my research was human error not double, triple checking before handing over the prescription.

35. Yes I believe that the PCT and MA carry more responsibility because they are the care givers. In a hospital the PCT answers the call light, checks vitals, checks urine output, food input. They are the eyes and ears of the nurse and doctor. They see the patients more in one shift than the nurses or doctors. The MA sees the patient first. Most patients look at an MA as a friendly, outgoing, and easy to talk to person so they are more likely to open up to them. I had a primary care physician who told me I could ask three questions per visit. If I had more I would have to make another appointment, so I asked the nurse who was talking my vitals the questions that were minor and kept the major questions for the doctor. When I was hospitalized recently, I saw the nurse at pill and insulin time only. I saw the doctor once a day maybe. Every hour I saw the PCT who asked me if everything was ok, did I need anything. She checked my tray after I ate and my bathroom for anything there. The patients rely on the PCT and MA to fill the doctor and nurse in with the concerns they have.