Chapter 7: Workbook Q&A's

What are 5 purposes served by a patient's medical record?

1. provide a format for tracking, documenting, and maintaining a patient's communication data, both inside and outside a health care facility; 2. they provide documentation of a patient's continuing health care, from birth to death; 3. they provide a foundation for managing a patient's health care; 4. they serve as legal documents in lawsuits; 5. and they provide clinical data for education, research, statistical tracking, and assessing the quality of health care.

which federal statute protects patient's with histories of substance abuse regarding the release of information about treatment?

Confidentiality of Alcohol and Drug Abuse Patient Records

Dr. Wellness also sees patients at Anytown General Hospital, where he maintains records of hospital stays, procedures, and emergency room visits. To whom do these records belong?

Anytown General Hospital

Dr. Wellness works as an employee of Anytown Medical Clinic. Who owns the records of his patients?

Anytown medical clinic

4 examples of HIT

EHR's, personal health records, electronic prescribing, and privacy and security of EHR

assume you are in charge of releasing medical records to a third party. which of the following does not require written consent?

Release of the records for use in a lawsuit, in response to a courts subpoena duces tecum

Chapter 7 Review

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how long should medical records be kept?

2-7 years depending on state statute

how long should records pertaining to cancer patients be maintained?

30 years

What is the difference between medical record, EMR, and EHR.

A medical record for a patient refers to a patient's visits to one health care facility. The health record covers all of a patient's health care issues and covers all health care facilities the patient may have visited.

what is the doctrine of professional discretion?

A principle under which a physician can exercise judgment about showing patients who are being treated for mental or emotional conditions their records.

Define HIT.

Health Information Technology: electronic system health care professionals and increasingly patients use to store, share, and analyze health information

what are 3 reasons a medical facility might be requested to release a patient's medical records?

Insurance claims, lawsuits, and transfer by patient to another physician

when can a patient's written consent to release medical records might be waived?

Lawsuits, if subpoenaed in court

If an insurance company submits a request for medical records pertaining to an enrolled patient's outpatient foot surgery and you are responsible for sending the records, should you send the patient's entire file to be on the safe side, why or why not?

No. You should send just the records requested. Additional information is confidential.

If medical records are lost prior to the filing of a medical malpractice lawsuit, where the records are necessary, what might result?

The defendant in the lawsuit would have no record and thus would in all likelihood be liable

who owns the medical record?

The facility that created the records owns them, but the patient owns the information they contain.

what is needed before the medical facility can send a patient's medical record to the insurer?

Written permission from the patient

are you entitled to a copy of your medical record on request?

Yes, you are entitled to a copy of your medical record with the appropriate written release. However, a practitioner always has the right to not release specific information if it is deemed detrimental to your care

As the person who reviews requests for patients' medical records, do you need to know the purpose for which the data will be used? Explain your answer.

Yes, you need this information for office or hospital records and to be sure the request is legitimate and will not violate patient privacy.

which of the following is not a threat to the confidentiality of a patient's medical record?

a physician shows a patient's medical record to a consulting specialist

what is meaningful use?

a process in which a healthcare provider uses an EHR according to the guidelines set by the federal government

The cardinal rule for the method used to destroy medical records can be summarized as: The information must not be ______________.

able to be reconstructed

experts recommend that the process of destruction of medical records follow a written _________ and __________.

approved retention schedule; destruction policy

Five C's for correctly entering information into a medical record:

concise; complete; clear; correct and chronologically ordered

3 types of modifications that could be made to a patient's record:

correction- clarify inaccuracies found after the document is complete, addendum- to add new info, and amendment- used to clarify or correct info in the EHR *must have time, date, and who made the change*

a physician determines being treated for a mental condition may not see his medical records. this is known as:

doctrine of professional discretion

How long should a deceased patient's medical records be retained?

each state will specify a time period

What is the key information that must be contained in any modifications to the patient's medical record?

patient's permission in writing

how do you destroy medical record?

shred them, burn them, pulverize them

a written request from any attorney for the records of a patient is received in the office. what must accompany the request in order for the physician's office to provide copies of the record?

subpoena