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4.3 Health Information

Understanding the types of health information and the rules and regulations surrounding their use.

Critical Work Functions

    4.3.1 Understand the role and importance of health information to manage knowledge and mitigate error.
      4.3.2 Identify and understand health insurance documentation requirements.
        4.3.3 Identify and understand health documentation requirements.
          4.3.4 Maintain the security and confidentiality of patient records, per HIPAA & other related regulations.
            4.3.5 Understand the two-way flow of information and data through the medical organization (originating with both patient and provider).
              4.3.6 Ensure documentation in health records reflect completeness, accuracy, timeliness, appropriateness, quality, integrity, and authenticity as required.
                4.3.7 Use medical terminology within a scope of practice in order to interpret, transcribe and communicate information, data and observations.
                  4.3.8 Use appropriate procedures for submitting and accessing medical information through a Health Information Exchange.
                    4.3.9 Understand the importance of using secure measures to transmit and dispose of documents and records.
                      4.3.10 Describe and explain the content areas of the medical health record (paper, electronic, hybrid).
                      • History – what care has been provided and what is outstanding
                      • SOAP (Subjective, Objective(s), Assessment, Plan)
                      • Outcomes of care provided and responses to the plan of care
                      • Current patient status & assessments
                      • Support decisions based on assessments to drive new plans of care
                      • Diagnoses
                      • Treatments, procedures
                      • Progress notes
                      • Laboratory results
                      • Consents
                      • Nursing and other therapeutic monitoring reports
                      • Administrative and referral documentation
                      • Discharge summary and instructions
                      4.3.11 Discuss the legal use of correct medical terminology in the medical health record.
                      • Abbreviations
                      • Acronyms
                      • Diagnostic and procedure terms
                      • Roots, prefixes, suffixes, eponyms
                      4.3.12 Delineate the role of the health care provider in record keeping and documentation.
                      • Confidentiality
                      • Record retention and disposal
                      • Release of information documentation
                      4.3.13 Health Information Exchange
                      • Access, retrieval, and submission procedures
                      • Software