2023 BONEWIT-WEST: Clinical Procedures for Medical Assistants, 10th Edition Chapter 1

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The medical record serves as a legal document. PHI includes health information in any form that contains patient-identifiable in- formation. A therapeutic service report documents the assessment... and treatment designed to restore a patient’s ability to function An example of a hospital document is a discharge summary report. Diabetes mellitus is an example of a familial disease. The medical assistant should make sure to document a procedure before performing it. . A symptom is any change in the body or its functioning that indicates the presence of disease. A feeling of dizziness or light-headedness is known as vertigo . Excessive perspiration is known as flatulence. Pain is an example of an objective symptom. The purpose of HIPAA is to provide patients with more control over the use and disclosure of their health information. . An example of a diagnostic procedure report is a urinalysis report. . A laboratory report is a report of the analysis or examination of body spcimens. The health history provides subjective data about a patient to assist the provider in arriving at a diagnosis. The family history is a review of the health status of the patient’s blood relatives. The chief complaint is the symptom causing the patient the most trouble. The social history includes information on the patient’s lifestyle, such as health habits and living environment. The patient’s name must be included at the beginning of each entry documented in the patient’s medical record. A decrease in the amount of water in the body is known as edema. Cyanosis is an example of an objective symptom. 21. List three functions of the medical record. 22. What is the meaning of the acronym HIPAA? 23. What is the purpose of the HIPAA privacy rule? 24. Who must comply with HIPAA? 25. What is a Notice of Privacy Practices? 26. What is protected health information? Health information in any form (written, 27. List examples of when HIPAA does not require written consent for the use or disclosure of a patient’s health information in the following categories: [Show More]

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