NR599 Week 8 Final Exam study Guide.2020
Ethical decision making
This refers to the process of making informed choices about ethical d... [Show More] ilemmas based on a set of standards differentiating right from wrong.
1) autonomy-the right to choose for himself or herself
3) veracity-right to truth
4) privacy-the right of privacy avoids conflict and promotes harmony
5) beneficence-actions performed that contribute to the welfare of
6) fidelity-right to what has been promised
Telehealth- 3 broad methods of digital care delivery that are "away" from the patient-means "healing at a distance"
1) telemedicine (stationary scheduled remote diagnostics of health status)
2) remote management/monitory/coaching (stationary home or facility-based, with scheduled and as-needed remote transmission of health status
3) Mobile health (mHealth) "community" groups/social media (wearable mobile patient-generated health data with scheduled and asneeded remote transmission of health status
a) transmitting clinical date for assessment, diagnoses, or disease
b) promoting disease prevention and good health
c) using telephone and videographic technologies to provide health advice in emergent cases
d) using real time video i.e: exchanging health services or video conferencing
Apps Providing Access to Electronic Copies
Apps for General Patient Education
Generic Aids or General Purpose Apps
Apps as Educational Tools
Apps Automating Office Operations
Some mobile apps may meet the definition of a medical device but because they pose a lower risk to the public, the FDA intends to exercise enforcement discretion over these devices (meaning it will not enforce requirements under the FD&C Act). One example is a mobile app that makes a light emitting diode (LED) operate. If the manufacturer intends the system to illuminate objects generally (i.e., without a specific medical device intended use), the mobile app would not be considered a medical device. If, however, through marketing, labeling, and the circumstances surrounding the distribution, the mobile app is promoted by the manufacturer for use as a light source for providers to examine patients, then the intended use of the light source would be similar to a conventional device such as an ophthalmoscope.
FDA Oversight for Medical Devices
The Food and Drug Administration (FDA) (2013) recognizes the extensive variety of actual and potential functions of mobile apps, the rapid pace of innovation in mobile apps, and the potential benefits and risks to public health represented by these apps. The FDA intends to apply its regulatory authorities to select software applications intended for use on mobile platforms. Given the rapid expansion and broad applicability of mobile apps, the FDA is issuing this guidance document to clarify the subset of mobile apps to which the FDA intends to apply its authority.
Many mobile apps are not medical devices, meaning such mobile apps do not meet the definition of a device by the Federal Food, Drug, and Cosmetic Act (FD&C Act); therefore, the FDA does not regulate them.
According to Healthit.gov (2014) Protecting Your Health Information, the privacy and security of patient health information is a top priority for patients and their families, health care providers and professionals, and the government. This was also previously discussed under HIPAA. It also requires that "key persons and organizations that handle health information to have policies and security safeguards in place to protect your health information whether it is stored on paper or electronically."
Hard to maintain due to social media and use of mobile devices such as smartphones, they are being utilized in treatment rooms around the globe, Providers need to be aware of institutional policies regarding audio/video recordings by patient and families, requires two-party consent, sometimes enthusiasm for patient care and learning can lead to ethics violations.
Another federal regulatory agency with a role in the privacy and security of health care data is the Food and Drug Administration (FDA). The FDA oversees the safety of medical devices, which includes addressing the management of cybersecurity risks and hospital network security. Recent guidelines issued (FDA, 2013) recommend that medical device manufacturers and health care facilities take steps to ensure that appropriate safeguards are in place to reduce the risk of failure caused by cyberattack. This could be initiated by the introduction of malware into the medical equipment or unauthorized access to configuration settings in medical devices and hospital networks. The consequences of not adequately addressing these risks could be dire. As medical devices are increasingly integrated within health care environments, there will be a need for vigilance toward cybersecurity practices to ensure all systems are adequately protected and patients remain safe from harm. Nurse Informaticists are frequently called on to evaluate safety and effectiveness of new devices and software. Considerations of cybersecurity must be included in any evaluation process.
Health Information Portability and Accountability Act (HIPAA)
HIPAA was enacted in 1996. While it is best known among consumers and healthcare professionals for its protection of personal health information (PHI) and the additional forms that each of us are asked to sign when we go to provider offices, HIPAA also ensures portability of insurance for individuals moving from one job to another, legal protection for PHI, and mandates standards for the electronic data interchange of healthcare data for encounter and claims information, and was intended to simplify the claims submission process by eliminating paper claims. HIPAA established legal sanctions for institutions and individuals who fail to protect PHI. As healthcare professionals, we are cognizant of HIPAA requirements before we share PHI via writing, electronic means, faxes, telephone, or in person. Specific measures to protect PHI include limiting record access to individuals with a right to know, signed disclosures to release information, encryption of e-mail and files, fax cover sheets, designated persons who may receive PHI, and the use of passwords to guarantee that PHI is only disclosed with persons designated by the consumer as having a right to know. HIPAA has also changed sign-in procedures for patients, disposal of forms containing PHI, and how we use whiteboards to show patient information.
• ICD-10 Coding (International Classification of Diseases)
Currently, we are in the tenth revision of the system, and , therefore, the classification system is known as ICD-10 . ICD-10 codes are shorthand for the patient's diagnoses, which are used to provide the payer information on the necessity of the visit or procedure performed. This means that every CPT code must have a diagnosis code that corresponds.
Evaluation and Management Coding
Before you can determine your E&M, code you must first identify the p lace of service, type of service , and the patient status. The place of service refers to where the service was rendered There are several categories to choose from, but the two most common are the inpatient and outpatient settings. This is pretty straightforward. The type of service refers to t he type of service provided . Some examples of types of services include consultation, hospital admission, office visit, and so forth. Again, pretty straightforward. As a student in your practicum rotations, nearly all of your place s and types of service will be outpatient office visits. Finally, you need to identify the patient's status. Patient status refers to whether or not the patient is a new patient or an established patient of your practice.
By definition, a new patient is one who has not received professional service from a provider from the same group practice within the past 3 years. Conversely, an established patient has received professional service from a provider of your office within the last 3 years.
There are three key components that determine risk-based E&M codes.
3. Medical Decision Making (MDM) ivo
Reimbursement codes are assigned and contingent upon data inpur from clinical team members based on a summative review of the clinical record by trained coders. This is critically important intersection between the clinical and administrative teams. if the patient encounter, procedure, or diagnosis are incorrectly entered into a clinical management system, the billing and coding process will also be incorrect. Providers play an important role in ensuring the success of the business by clearly identifying the diagnosis and service codes are appropriate for each patient visit. It is imperative for APNs to have knowledge of the link between billing, coding, and the EHR.
Diagnosis related groups (DRGs) or Major diagnostic categories (MDCs) systematically group these more specific codes into meaningful broader categories. DRG group is to facilitate payment through the prospective payment system, MDCs organize diagnoses that affect similar physiological systems. Primary purpose is for billing.
Clinical Support Tools
Clinical decision support (CDS) as a process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assessments, recommendations, or other forms of guidance that are then presented to a decision-making recipient or recipients that can include clinicians, patients, and others involved in care delivery. CDS tools existed prior to development of EHRs. Historical examples include practice guidelines carried in clinicians' pockets, patient cards used by providers to track a patient's treatments, and tables of important medical knowledge. The primary goal of implementing a CDS tool is to leverage data and the scientific evidence to help guide appropriate decision making. CDS tools include but are not limited to:
Workflow is a term used to describe the action or execution of a series of tasks in a prescribed sequence. Another definition of workflow is a progression of steps (tasks, events, interactions) that constitute a work process, involve two or more persons, and create or add value to the organization's activities. In a sequential workflow, each step depends on the occurrence of the previous step; in a parallel workflow, two or more steps can occur concurrently. The term workflow is sometimes used interchangeably with process or process flows, particularly in the context of implementations. Observation and documentation of workflow to better understand what is happening in the current environment and how it can be altered is referred to as process or workflow analysis. A critical aspect of the informatics role is workflow design. Nursing informatics is uniquely positioned to engage in the analysis and redesign of processes and tasks surrounding the use of technology. [Show Less]