Documentation Correct Answer: is the record of clinical observations and care a patient receives at a health care facility. Documentation is used to
... [Show More] communicate relevant patient info among health care professionals. It also serves as the basis of information conveyed to third party payers who are responsible for reimbursing providers. third party payers include insurance companies, Medicare, and Medicaid.
Informed Consent Correct Answer: providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved giving patients an opportunity to ask questions before medical intervention is provided.
Implied Consent Correct Answer: A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed. Signature not required.
ARRA American REcovery & Reinvestment Act Correct Answer: in 2009 was signed into law. A section of the law, the HITECH Act, includes changes to the HIPAA Privacy Rule. This sections discusses those changes and how they affect documentation procedures.
Protected Health Information PHI Correct Answer: the Privacy Rule has a specific definition for PHI: individually indentifiable health info transmitted by electronic media, maintained in any electronic medium, or maintained in any other form or medium. this includes paper forms or documents verifying conversations. To meet the definition of PHI, the info must be held or transmitted by a covered entity or a business associates BA.
Covered Entities Correct Answer: are any health plan, clearinghouse or providers. BAs are any indiv groups or organizations who are not members of the covered entity's workforce that perform functions or activities on behalf of or for a covered entity. These activities can involve patient health info.
Individually Identifiable means Correct Answer: Documents that either identify the person or provide enough info that the person could be identified, Info that includes past, present, or future physical or mental health conditions, Info that includes provision of health care and info that includes payment for the provision of health care.
Use Correct Answer: the way PHI is handled internally by a covered entity or its business associate.
Clearing house Correct Answer: A [Show Less]