which of the following components of a patient care report are confidential

What is a patient care report (PCR)?

Patient care report (PCR) Prehospital care report, is the legal document used to record all aspects of the care your patient recieved, from initial dispatch to arrival at the hospital The report serves the following six functions :

What are the three areas of patient care covered by HIPAA?

HIPAA was enacted to encompass three areas of patient care: Portability of insurance or the ability of a patient/worker to move to another place of work and be certain that insurance coverage is not denied Detection and enforcement of fraud and accountability

Why is patient confidentiality important in healthcare?

Patient Confidentiality Ensuring the security, privacy, and protection of patients' healthcare data is critical for all healthcare personnel and institutions. In this age of fast-evolving information technology, this is truer than ever before.

How do you protect patient information in healthcare?

This means restricting access and uses of the patient information to other members of the healthcare team. Additionally, procedures should be implemented to help protect electronic health records from unauthorized access, alteration, and deletion.

What are the components of a patient care report?

Patients name and the chief complaint, nature of the illness, or mechanism of injury. Detailed information, such as pertinent negatives and findings of a more detailed physical exam. Any medical history not already given. The patient's response to treatment given en route.

Which format should be used when writing the narrative section of a patient care report?

SOAP NOTE: Traditionally, the SOAP method is used for narrative documentation and includes all pertinent information. SOAP is an acronym for a patient care report that includes: Subjective: details relative to the patient's experience of the illness or injury like onset time, history, complaint, etc.

What is the purpose of the narrative section of the patient care report?

Detailed explanation of medical necessity: Your narrative should be detailed and provide a clear explanation for why the patient needed to be transported by ambulance. Include what the medical reasons were that prevented the patient from being transported by any other means.

Which of the following components are needed to prove negligence quizlet?

Which of the following components are needed to prove negligence: abandonment, breach of duty, damages, and causation; duty to act, breach of duty, injury/damages, and causation; breach of duty, injury/damages, abandonment, and causation; duty to act, abandonment, breach of duty, and causation.

When providing a patient report via radio You should protect the patient's privacy by?

When providing a patient report via radio, you should protect the patient's privacy by: not disclosing his or her name. You are providing care to a 61-year-old female complaining of chest pain that is cardiac in origin.

How do you write a patient report?

III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•

What are the different components of a SOAP note?

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan.

What should be included in a narrative PCR?

Present the facts in clear, objective language. Other important details to include are SAMPLE (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to present injury) and OPQRST (Onset, Provocation, Quality of the pain, Region and Radiation, Severity, and Timeline).

What seven items should be included in the radio report given about a patient?

Parts of the EMS radio report to the hospitalUnit's identification and level of service (ALS or BLS)Patient's age and gender.Estimated time of arrival (ETA)Chief complaint and history of present illness.Pertinent scene assessment findings and mechanism of injury (i.e. fall, or motor vehicle accident)More items...•

Which of the following is not included in patient PHI information?

PHI only relates to information on patients or health plan members. It does not include information contained in educational and employment records, that includes health information maintained by a HIPAA covered entity in its capacity as an employer.

Which of the following components are needed to prove negligence?

In order to establish negligence, you must be able to prove four “elements”: a duty, a breach of that duty, causation and damages.

Which of the following most accurately defines negligence?

Which of the following MOST accurately defines negligence? Deviation from the standard of care that may result in further injury.

As an EMT, the standards of emergency care are often partially based on: Select one: A. Patient care cannot be discredited based on poor documentation. B. EMTs are not liable for any actions that are accurately documented. C. It is difficult to prove actions were performed if they are not included on the report. D. Incomplete reports are common and accepted in EMS.

C. It is difficult to prove actions were performed if they are not included on the report.

During your monthly internal quality improvement (QI) meeting, you review several patient care reports (PCRs) with the staff of your EMS system. You identify the patient's name, age, and sex, and then discuss the treatment that was provided by the EMTs in the field. By taking this approach to the QI process, you: Select one: A. violated the patient's privacy because you should have discussed the information only with the EMTs involved. B. acted appropriately but must have each EMT sign a waiver stating that he or she will not discuss the cases with others. C. adequately safeguarded the patient's PHI because the cases were discussed internally. D. are in violation of HIPAA because you did not remove the PHI from the PCR beforehand.

D. are in violation of HIPAA because you did not remove the PHI from the PCR beforehand.

In which of the following circumstances can the EMT legally release confidential patient information? Select one: A. The family requests a copy for insurance purposes B. The patient is competent and signs a release form C. A media representative inquires about the patient D. A police officer requests a copy to place on file

B. The patient is competent and signs a release form

In which of the following situations does a legal duty to act clearly exist? Select one: A. The EMT hears of a cardiac arrest after his or her shift ends. B. A call is received 15 minutes prior to shift change. C. A bystander encounters a victim who is not breathing. D. The EMT witnesses a vehicle crash while off duty.

B. A call is received 15 minutes prior to shift change.

Maintaining the chain of evidence at the scene of a crime should include: Select one: A. quickly moving any weapons out of the patient's sight. B. making brief notes at the scene and then completing them later. C. not cutting through holes in clothing that were caused by weapons. D. placing the patient in a private area until the police arrive.

C. not cutting through holes in clothing that were caused by weapons.

Putrefaction is defined as: Select one: A. decomposition of the body's tissues. B. blood settling to the lowest point of the body. C. separation of the torso from the rest of the body. D. profound cyanosis to the trunk and face.

A. decomposition of the body's tissues.

The EMT's scope of practice within his or her local response area is defined by the: Select one: A. medical director. B. state EMS office. C. local health district. D. EMS supervisor.

A. medical director.

To help protect patients, EMS agencies are required to have __________. Select one: A. public forums with their medical director B. online access to patient records C. a privacy officer to answer questions D. an anonymous reporting system

C. a privacy officer to answer questions

When is forcible restraint permitted? Select one: A. Only if consent to restrain is given by a family member B. When the patient poses a significant threat to self or others C. Anytime that the EMT feels threatened D. Only if law enforcement personnel have witnessed threatening behavior

B. When the patient poses a significant threat to self or others

What is PHI in HIPAA?

HIPAA broadly defines PHI as any health information that is transmitted or maintained in electronic media. It is also important to know that PHI is not only restricted to electronic transmission of media, but also any oral communications of individually identifiable health information constitutes PHI.

What are the three areas of HIPPA?

HIPPA was enacted to encompass three areas of patient care: Portability of insurance or the ability of a patient/worker to move to another place of work and be certain that insurance coverage is not denied. Detection and enforcement of fraud and accountability.

Does HIPAA apply to healthcare workers?

HIPAA applies to all healthcare institutions and healthcare workers, who submit claims electronically. For example, if you are a healthcare worker and transmit or even discuss PHI with others who are not involved with that patient's care, then you violate HIPAA. However, there is a HIPAA rule that permits disclosure of PHI without prior obtained consent for healthcare operations, treatment, and payment. This includes consultation between providers regarding a patient, referring a patient and information required by law for public health safety and reporting. These exceptions cover the majority of clinical uses of PHI. Other disclosures demand explicit patient consent and apply to everyone in a healthcare facility, including:

What should be included in maintaining the chain of evidence at the scene of a crime?

Maintaining the chain of evidence at the scene of a crime should include:#N#Select one:#N#A. quickly moving any weapons out of the patient's sight.#N#B. making brief notes at the scene and then completing them later.#N#C. not cutting through holes in clothing that were caused by weapons.#N#D. placing the patient in a private area until the police arrive.

How to respond to a home of a 59 year old man who is unconscious; has slow, shallow breathing

They further state that there is a DNR order for this patient, but they are unable to locate it. You should:#N#Select one:#N#A. begin treatment and contact medical control as needed. #N#B. honor the patient's wishes and withhold all treatment.#N#C. transport the patient without providing any treatment.#N#D. decide on further action once the DNR order is produced.

How does confidentiality affect patient safety?

The confidentiality provisions will improve patient safety outcomes by creating an environment where providers may report and examine patient safety events without fear of increased liability risk. Greater reporting and analysis of patient safety events will yield increased data and better understanding of patient safety events.

When did the Patient Safety and Quality Improvement Act of 2005 become effective?

The regulation implementing the Patient Safety and Quality Improvement Act of 2005 (PSQIA) was published on November 21, 2008, and became effective on January 19, 2009. View the Patient Safety Rule - PDF (42 C.F.R. Part 3). PSQIA establishes a voluntary reporting system to enhance the data available to assess and resolve patient safety ...

What is PSQIA reporting?

PSQIA establishes a voluntary reporting system to enhance the data available to assess and resolve patient safety and health care quality issues.

What is PSQIA in healthcare?

PSQIA provides for the establishment of Patient Safety Organizations ( PSOs) to receive reports of patient safety events or concerns from health care providers and to provide analyses of these events to the reporting providers.

What are the elements of a narrative?

1. Dispatch & Response Summary. The dispatch and response summary provides explicit details of where the unit was dispat ched, what they were dispatched for and on what priority.

What is a safety summary?

The safety summary details a couple of different things. It details how the patient was transferred from the scene to the stretcher and then to the ambulance. It also details what safety measures were performed, such as safety straps, while transferring the patient.

How can healthcare professionals uphold patient confidentiality?

Healthcare professionals can uphold confidentiality in their own practice, among colleagues, and at their medical facilities by: Following HIPAA guidelines. This requires keeping up to date on HIPAA rule changes to avoid penalties and legal problems.

What is patient confidentiality?

Patient confidentiality refers to the right of patients to keep their records private and represents physicians’ and medical professionals’ moral and legal obligations in handling patients’ sensitive medical and personal information.

How many healthcare data breaches are there?

But healthcare data breaches remain a threat. According to HIPAA Journal, 3,054 healthcare data breaches between 2009 and 2019 have led to the “loss, theft, exposure, or impermissible disclosure of 230,954,151 healthcare records.”. Therefore, physician cybersecurity is vital for protecting patient health records.

Why is patient confidentiality important?

Patient confidentiality is necessary for building trust between patients and medical professionals. Patients are more likely to disclose health information if they trust their healthcare practitioners. Trust-based physician-patient relationships can lead to better interactions and higher-quality health visits.

What is the HHS security risk assessment tool?

Together with the Office of the National Coordinator for Health Information Technology (ONC), HHS offers a Security Risk Assessment Tool that helps guide healthcare practitioners through the risk assessment process.

What is the acronym for the Centers for Disease Control and Prevention?

Centers for Disease Control and Prevention, Confidentiality and Consent — Information about the legal and ethical concerns of patient confidentiality. American Medical Association (AMA), HIPAA — HIPAA privacy and security resources, including articles, FAQs, and tools.

What are some examples of when physicians are legally permitted to share their patient’s health information without permission?

Below are some examples of when physicians are legally permitted to share their patient’s health information without permission: Patient safety. A healthcare professional can breach patient confidentiality to protect a patient’s safety.