RHIA EXAM PREP DOMAIN II QUESTIONS AND ANSWERS GRADED A

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RHIA EXAM PREP DOMAIN II QUESTIONS AND ANSWERS GRADED A Master or Enterprise patient index ✔is critical to identifying patients and ensuring proper record linkage The health record consist of �... �handwritten notes, transcribed reports, electronic data, digital images Continuity of care ✔is improved by the sharing of patient information between providers Standards and regulations ✔have a great impact on what is documented in the health record The American College of Surgeons (ACS) ✔developed the minimum standards for hospitals in the early 20th century. The Joint Commission succeeded the ACS in standardization The health record ✔is the major source of information about any healthcare facility and is routinely surveyed to obtain knowledge about the facilities care process or performance. State Licensure ✔establishes requirements for patient records content, format, retention and use. Licensure is required for healthcare facilities to remain in operation. By laws and rules are ✔developed by the medical staff and approved by the (BOT) board of trustees or governing body in the facility. Longitudinal health record ✔contains various encounters, records from numerous health care delivery settings. It is valuable because it reduces medical errors, duplication of testing and repetition. It improves decision making for providers and care for the patients The medical record is ✔maintained in two broad areas Administrative and demographic and clinical data The legal health record ✔must identify the sources, medium, paper images, video, or audio, and location Meaningful use ✔functional and quality reporting criteria 3 subsystems of the United States legal system ✔Judicial, Regulatory, and Administrative Judicial legal system ✔allows a wronged party to seek retribution Regulatory legal system ✔regulates how an action is met of seeking retribution Administrative legal system ✔controls government administrative operations such as licensing, accrediting bodies, Medicare, Medicaid, and federal and state government programs Federal Register ✔publishes revisions to existing administrative rules for healthcare related information updated by MCOP and HIPAA Civil Law ✔most healthcare encounters fall into this category HIPAA privacy rule ✔criminal provisions only have felony crimes Torts ✔harm through wrongful conduct and seeks compensation and to discourage the wrongdoer from continuing wrongful acts Three categories of tort liability exist ✔negligence, intentional torts, and products liability Accreditation Agencies ✔are offered through non-governmental agencies Hospital standards ✔are developed by Joint Commission Accreditation ✔is voluntary but can be a requirement for some licensures Joint Commission focus ✔is not legally mandated. the focus is on the entire hospital Medicare Condition of Participation ✔sets standards for hospitals and are government regulations 1965 Griswold v. Connecticut case ✔recognized the need/right to privacy California ✔recognized the right to privacy through its states constitution. 1996 HIPAA enacted by Congress ✔addresses fraud and abuse in the healthcare system The controlled substance act ✔controls the use of narcotics, depressants and stimulants. drugs are classified into schedules The Federal Food, Drug and Cosmetic Act ✔includes medical device amendments of 1976 and covers products, most equipments and supplies Retention periods for the health record ✔is determined by federal and state laws HIPAA ✔does not provide access to oral information, psychotherapy notes, information compiled for civil, criminal or administrative action Violation of HIPAA prior to 2/18/2009 ✔$100 per violation Violation of HIPAA after 2/18/2009 and (CE) covered entity did not know ✔not less than $100 or more than 50,000/ violation not to exceed 1.5 million during a calendar year HIPAA violation due to reasonable cause and not willful neglect ✔not less than $1,000 or more than $50,000/violation HIPAA violation due to willful neglect and corrected in a 30 day period ✔not less than 10,000 or more than 50,000/ per violation HIPAA violation due to wilfull neglect and not corrected ✔not less than $50,000/violation or more than 1.5 million / violation Beneficence ✔release of information to benefit the patient such as payment for a claim Non-maleficence ✔non-release of information to groups such as the media requesting information on a famous person Autonomy ✔ensures only the patient makes deci [Show More]

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