Subjective
Objective
Assesment
Plans
Education
Response
How important is an effective, easy-to-use, and easy-to-access filing system to the efficiency of the ambulatory care setting?
It saves considerable time
Problem oriented medical record
**electronic medical record
Create
store
edit
retrieve patient data
fully recognized as a legal document
**Transfer of data - EMR's can be ____, ____, _____
*manual medical records can be _____, or _______
providers reserve patient medical records for _____ of practice and should have a __________ system
Source oriented medical record (SOMR's)
does not have a problem oriented list
POMR's (problem oriented medical record)
DOES have a problem oriented list.
Multiple problems
reminder that some action needs to be taken at DATE IN THE FUTURE
Providers Initials
Date Stamp
Straight numeric
Terminal digit
Middle digit
HIPAA compliant
Confidentiality of charts
Closed files are usually kept?
Three types of cabinets used in medical clinics are?
to identify major sections of file folders
The three filing systems that are commonly used in the ambulatory care setting are ?
alphabetic
numeric
subject
**What types of files could be purged in the medical office?
Active files
Inactive files
Closed files
List four advantages of EMR's
Less error's
Multiple users
Not easily misplaced
Office storage space not required
**Two types of medical records?
Medical records are the property of?
The providers who create them
When identical names are being indexed or filed, the system for indexing most preferred in a medical clinic is?
The birthdate or Social Security number
Tab-Alpha system
Alpha Z system
Customized color coding systems
most common filing method
This guidance remains in effect only to the extent that it is consistent with the court’s order in Ciox Health, LLC v. Azar, No. 18-cv-0040 (D.D.C. January 23, 2020), which may be found at
//ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2018cv0040-51. More information about the order is available at //www.hhs.gov/hipaa/court-order-right-of-access/index.html. Any provision within this guidance that has been vacated
by the Ciox Health decision is rescinded. YouTube embedded video: HIPAA: Your Health Information, Your Rights. Most of us believe that our medical and other health information is private and should be
protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals' protected health information, whether electronic, written, or oral. The Security Rule is a Federal law that requires security for health information in electronic form. OCR has teamed
up with the HHS Office of the National Coordinator for Health IT to create Your Health Information, Your Rights!, a series of three short, educational videos (in English and option for Spanish captions) to help you understand your right under HIPAA to access and receive a copy of your health information. OCR has teamed up with the HHS Office of the National Coordinator for Health IT to create this one-page fact sheet, with illustrations, that provides an overall summary of your
rights under HIPAA: We call the entities that must follow the HIPAA
regulations "covered entities." Covered entities include: In addition, business associates of covered entities must follow parts of the HIPAA regulations. Often, contractors, subcontractors, and other outside persons and companies that are not employees of a covered entity will need to
have access to your health information when providing services to the covered entity. We call these entities “business associates.” Examples of business associates include: Covered entities must have contracts in place with their business associates, ensuring that they use and disclose your health information properly and safeguard it appropriately. Business associates must also have similar contracts with subcontractors. Business associates (including subcontractors) must follow the use and disclosure provisions of their contracts and the Privacy Rule, and the safeguard requirements of the Security Rule. Many organizations that have health information about you do not have to follow these laws. Examples of organizations that do not have to follow the Privacy and Security Rules include: Health insurers and providers who are covered entities must comply with your right to: You should get to know these important rights, which help you protect your health information. You can ask your provider or health insurer questions about your rights. Learn more about your health information privacy rights. The Privacy Rule sets rules and limits on who can look at and receive your health information To make sure that your health information is protected in a way that does not interfere with your health care, your information can be used and
shared: Your health information cannot be used or shared without your written permission unless this law allows it. For example, without your authorization, your provider generally cannot: Sign Up for the OCR Privacy Listserv HIPAA Right of Access Videos
HIPAA Right of Access Infographic
HIPAA General Fact Sheets
Who Must Follow These Laws
Who Is Not Required to Follow
These Laws
What Information Is Protected
How This Information Is Protected
What Rights Does the Privacy Rule Give Me over My Health Information?
Who Can Look at and Receive Your Health Information
Keep up-to-date as OCR releases updated health information privacy FAQs, guidance, and technical assistance materials.
Content created by Office for Civil Rights (OCR)
Content last
reviewed January 19, 2022