4604424
Description
Flashcards by Sydney Franko, updated more than 1 year ago
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Created by Sydney Franko
about 8 years ago
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| Question | Answer |
| What are the 10 reasons we Document? | o Legal Protection o Memory Aid o Legal Requirements o Professional Standards o Improved Communication o Insurance Requirements o Discharge Decisions o Improved Care o Injury Surveillance o Outcomes Assessment |
| What is Problem-Oriented Medical record? (POMR) | A system of medical record keeping that organizes information around the physically active patient's specific complaints |
| What is Focus Charting | A less cumbersome alternative to the POMR medical record-keeping method |
| What is Charting by Exception? | Its name implies, is a method in which only patients responses that vary from predefined norms are noted on the record |
| What is Computerized Documentation? | The use of computers for keeping sports medicine records was described as early as 1982, and the products available to athletic trainers have been increasing in number and utility ever since. |
| What does a report of Special Procedures include? | -Isokinetic strength test -Blood test -Urinalysis -X-rays or other imagining procedures -Surgical reports -Cardiac assessments |
| Define FERPA | Family Educational Rights and Privacy Act: requires educational institutions to receive formal written consent from students before they can disclose educational records to a third party |
| Define HIPAA | Health Insurance Portability Accountability Act: To help employees transfer their health insurance when they switched employers, to ensure that their health information would remain private, and to give people more access to their own health care information. |
| What are the 7 areas Athletic Trainers need to spend attention to with regard to HIPAA rules | 1. Obtain consent for treatment 2. Obtain authorization to release health information 3. Release only the minimum necessary information 4. Safeguard patient information 5. Observe state laws governing the treatment of a minor's health information. 6. Do not combine authorizations except for research purposes 7. Business associates must safeguard patient information |
| What information should be in the medical record concerning the insurance? | -Expected payer or payers -Insured's name -Patient's relationship to the insured -Employment data and insurance numbers |
| What are program administration records? | More general records and are usually organized around subfunctions of the sports medicine program |
| What are Coaches Reports? | Providing coaches with daily written reports of the health status of their athletes |
| What Budget Information is important to athletic trainers specifically? | AT's with financial authority must maintain accurate records of all financial transactions |
| What is Nonmedical Correspondence? | Comprises letters and memoranda not associated with a specific patient's health status. |
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