Module 2 Workbook 2,5,6,11 completed
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Chapter 2 Legal Issues in Health Information Management- Noell Davila
One of the most hotly contested “right-to-die” cases involving the lack of an advance directive
was that of Terri Schiavo, a disabled Florida woman who was in a persistent vegetative state
and received nutrition and hydration through a feeding tube. On March 31, 2005, following
years of legal battles involving her husband (who supported the removal of the feeding
tube) vs. her parents and siblings (who supported the continued use of the feeding tube),
Schiavo passed away after her feeding tube had been removed 13 days earlier.
a.
What are the differences between a living will and a durable power of attorney for
healthcare decisions?
A living will in health is the primary healthcare directive for how a person plans to be
cared for in a situation when they cannot speak for themselves, so the document
should be as specific as possible. Like the case of Terri Schiavo, it is not often that we
know when and where we may fall ill and need these things, so it is important to make
sure that it is created and given to someone that is trusted to ensure that the person
receives his or her preferred medical treatment. Included in a living will should be a
clear outline of any treatments you do not wish to receive to avoid instances like the
Schiavo case. Additionally, a living will can include extreme measures, and topics like
resuscitation, desired quality of life, and end of life treatments.
In the event that a person does not have a living will prepared, the secondary option is
that a durable power of attorney is given to the person you want to make medical
decisions for you in an emergency; think of it as a “plan B”. Although what is written in
a living will can always triumph a durable power of attorney, the idea is that the
person that you have chosen is trusted as your proxy, and it is their duty and
responsibility to answer unforeseen circumstances for you.
b.
Terri Schiavo had neither a living will nor a durable power of attorney for healthcare
decisions. Do you think that one of these documents vs. the other would have been
more effective to clarify her wishes? To minimize the dissension between her husband
and her blood relatives?
In Terri Schiavo’s case, a living will would have been the most effective document to
carryout her medical wishes. Because spouses and families often believe that they
know what is best for their loved ones, having a durable power of attorney could have
just created more issues and distain amongst the people who cared about her the
most. The best thing for this case would have been hearing what she wanted from her
own words. She would have had to go through some estate planning with an attorney
to create the document, so they can trust that the decision was what she really
wanted and it would not be taken lightly. I believe that people deserve to go with
dignity and that if that have a choice or a preference, it should be acknowledged.
Chapter 11 Data Privacy, Confidentiality, and Security- Noell Davila
1.
In 2011-2012, the Department of Health and Human Services conducted HIPAA audits to
evaluate the current level of HIPAA compliance among healthcare organizations, health
plans, and clearing houses. The findings indicated that small healthcare organizations
were often found to be out of compliance with the HIPAA regulations. What do you think
are the biggest barrier(s) to compliance with the HIPAA regulations among this
population of healthcare organizations?
According to research, the biggest barriers to compliance as it relates to the
population of healthcare organizations are; Use of free tools that provide security such
as online applications, mail accounts, and free EHR software put patient information at
risk of being unprotected. In order to be in compliance, both HIPPA and HIM
requirements should be understood and abided. The lack of education and support for
the individual people responsible for compliance is what their suffrage stems from.
HIPPA was created to protect the confidential information given by and for healthcare
patients in organizations; the expectation is that the Department of Health and Human
Services holds organizations to those standards and provides them with the support to
knowledge to be successful within the guidelines.
2.
A small counseling center received notification that a laptop that contained patient
information was stolen out of a workforce member’s care. Upon investigation, it was
determined that information on the workforce member’s laptop contained the following
information on approximately 980 individuals:
Social Security number
Date of birth
Address
Treating physician name
Diagnosis and clinical information
Phone number
Email address
Demographic information
Financial information
Health insurance information
Treatment information
Medication information
The laptop that was stolen was password protected; however, it did not contain any
encryption software. While no reports of identity theft have been reported, it is
unknown what has been done with the laptop or the information on the laptop. All
individuals impacted by the data breach were notified by written letter of the data
breach. Each of the individuals impacted are encouraged to continue to monitor their
credit reports to watch for suspicious activity.
Questions:
a.
What could have been done to prevent this data breach from occurring?
It is my understanding that such information regarding patients should not be
available in a portable manner in any case. Laptops are very accessible and easy to
steal, so the reasonable action would have been to use desktops in the
organization. Typically, encryption software should be on computers with sensitive
information as well; the sole purpose for this type of software is to protect digital
information on computers in small organizations so that they do not have to
outsource.
b.
What should the organization do to prevent data breaches like this from happening
again?
In the future, the organization should be proactive in protecting its patient’s
information. By using desktop computers, adding security cameras, and using
security key cards to restrict access to individuals that are not privy to the
information, patient information would be better protected. Even when switching
information over to desktops, the computers should have encryption software
implemented
.
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Chapter 5 Clinical Classifications, Vocabularies, Terminologies, and Standards-
Noell Davila
Part 1:
ICD-10-CM
Go to web site
icd10data.com
Using 2023 ICD-10-CM Index, look up each term and determine the appropriate code for the
following diagnoses (note – appropriate manner would not be to use the search bar but rather
determine which chapter (as distinguished by the 3-character ranges; example A00-B99
contains Infectious and parasitic diseases codes):
1.
Chronic hypertrophy of tonsils and adenoids- J35.3
2.
Recurrent direct left inguinal hernia with gangrene- K40.41
3.
Acute upper respiratory infection with influenza- J11.1
4.
Nondisplaced abduction fracture anterior acetabular column, subsequent encounter
with routine healing- S32.436D
5.
Dementia with aggressive behavior- F02.A11
, BUT POSSIBLY UNDER F02.C11
Part 2:
ICD-10-PCS
Using the 2023 ICD-10-PCS Codes, code the following procedures – all can be found in the
Medical and Surgical chapter
1.
Laparoscopic excision of right ovarian cyst- 0UB04ZZ
2.
Below knee amputation, distal portion, right leg- 0Y6H0Z3
3.
Liver transplant with donor matched liver- 0FY00Z1
Part 3:
Other classifications and terminologies:
NDC and RxNorm
Go to website:
http://dailymed.nlm.nih.gov
Search for drug “Lasix”
1.
Describe the “NDC” information found on this drug.
How many NDC codes do you see?
Locate the “label” – how many places do you notice the NDC code?
There are seven NDC codes included on the information tab. The unique numbers
differentiate and identify the drugs and packaging depending on the strength or
milligram of the drug. Each code is found on the packaging twice.
2.
Locate the “RxNorm” information.
How many RxCUIs are there for Lasix?
There are 15 RxCUIs for the Lasix drug aka furosemide tablet.
3.
Go to web site
https://mor.nlm.nih.gov/RxNav/
.
Search for drug “Lasix”.
Review the
available tabs and views.
Describe the information that is seen on this site.
How does
RxNorm differ from NDC (what is primary use of each?)
Under the search for the drug Lasix, the first graph lists the ingredients, brand name,
clinical drug components, branded drug components, clinical or branded drug pack,
dose form group and branded form group. The RxCUI includes the active and the
current history of the drug from when it was last released. There is a tab that would
usually include the drugs class type if it requires one, but since Lasix is a “BN” type
drug, it does not have a class. And finally, it lists the 1,386 drug interactions that could
involve furosemide. In the chart there is a column to list the severity of the drug
interaction if there is one, and it gives a description of what occurs with each
individual drug that it interacts with in the body.
Chapter 6 Data Management- Noell Davila
1. Review the PDF of power point slides from the National Cancer Registrars Association –
Registries and Certification (located in current D2L module!) and/or visit their website
https://www.ncra-usa.org/
and answer the following questions:
1.
What is the difference between hospital-based registry goals and population-based
registry goals?
Hospital-based registries contain data on all the patients with a specific type of disease
diagnosed and treated within the hospital; the focus is on clinical care that has been
provided and clinical administration. A population-based registry contains records for
people diagnosed with a specific type of disease who reside within a defined
geographic region. They collect a wide range of records including death certificates and
lab services of within the region.
2.
Who determines the abstracting rules for cancer registries?
Individual state central registries set forth the rules. Hospitals that are accredited
through the American College of Surgeons Commission on Cancer follow their
abstracting rules and standards, and cancer registries transmit abstract data to their
state’s cancer registry and, if the facility is ACoS/CoC-accredited, to the National
Cancer Data Base (NCDB).
3.
What is casefinding?
What are possible sources to locate cases?
Casefinding is a systematic method of identifying all eligible cases to be included in the
registry database, and to update cases that already exist in a database. The primary
locations to find cases are disease index, med oncology log, operation reports,
pathology reports, and radiology oncology reports. The next place that you may find
them are cytology reports, diagnostic images, discharge logs, and outpatient logs.
Why do they have a specific document/handout on quality?
Regularly monitoring casefinding enables the registrar to identify potential problems
and suggest corrections. The purpose of monitoring logs is to ensure complete
reporting of all reportable cases. This quality control function should be performed
semiannually, at a minimum, to allow for immediate correction of identified
underreported areas.
4.
Determine the steps that YOU would need to take to become a Certified Tumor Registrar
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There are three different paths to becoming a CTR, speaking for myself specifically, I
would be best served by following “path 3.” Because I am soon to be a graduate with a
bachelor’s degree, and I have already completed more than six college credit hours in
both human anatomy and human physiology.
Earn an Associate Degree or complete 60-Hours of College-Level Courses, including Six
College Credit Hours in Human Anatomy and Human Physiology.
Complete one year (1,950 hours) of Cancer Registry Experience
Pass the Certified Tumor Registrar (CTR) Exam
Maintain the CTR Credential with Continuing Education Courses
2. Does Georgia have a statewide immunization registry?
If you were not born in Georgia,
does your birth state have a statewide immunization registry?
If so, what is/are source of
data included in the registry?
The Georgia Immunization Registry was passed in 1992, and it is designed to collect
and maintain accurate, complete and current vaccination records to promote effective
and cost-efficient disease prevention and control.