| A | B |
|---|
| documenttion | logical consistant record |
| progress report | at each visit |
| SOAP | subjective objective assessment plan |
| chart info | released under court order or workers comp |
| EHR | electronic health record |
| encounters | documented and face to face |
| service provided, even a phone call | needs to be documented |
| HIPAA | health insurance portabile accountability act |
| business assoc, repair workers, cleaners | bound under hipaa |
| TPO | all others need permission |
| abuse | billing falsely type of abuse |
| NPI | national provider identifier |
| authorization release | dated/expiration/allows receiver access to specific info |
| fraud and abuse | large fines may be denied future govt access |
| fraud | always intentional with intent to benefit |
| respondeat superior | responsible for MA |
| Qui tam | whistle blowing against govt |
| pt access record | not for all of it, portions |
| supeona | appear and testify |
| supoena duces tecum | appear testify with item |
| de-identified | personal markers removed |
| pt owns | information |
| dr owns | records |
| medical standards of care | expeced reasonably of medical professional |
| malpractice | failure to follow medical standards of care |
| {rovacu ri;e | rules for protecting PHI |
| covered entities | health plans, clearinghouses and providers |
| informed consent | dr explains TX with risks and benefits |
| PHI | protected health information |
| discharge summary | pts CURRENT condition status final DX |
