Which of the following organizations requires unique identifiers for a patient's record?
CLIA
OSHA
HIPAA
CDC
The Correct Answer is C
A. CLIA: CLIA regulates lab testing but does not require unique patient identifiers.
B. OSHA: OSHA regulates workplace safety but does not require unique patient identifiers.
C. HIPAA (Health Insurance Portability and Accountability Act): This is correct. HIPAA requires the use of unique identifiers to protect patient privacy and ensure the confidentiality of medical records.
D. CDC: The CDC focuses on public health and disease control, not patient identifiers.
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Correct Answer is A
Explanation
A. Subjective: The chief complaint is a patient-reported symptom or concern and is documented in the subjective section of the progress note. This section includes the patient’s personal perspective and descriptions of their symptoms.
B. Objective: The objective section includes measurable or observable data, such as vital signs and physical examination findings, not the patient’s chief complaint.
C. Review of systems: The review of systems is a systematic approach to obtaining information about the functioning of various body systems but is not specifically where the chief complaint is documented.
D. Assessment: The assessment section contains the provider’s diagnostic impressions and conclusions about the patient’s condition, rather than the chief complaint.
Correct Answer is C
Explanation
A. The name of the person accompanying the patient: While this may be useful for certain procedures, it is not generally essential for scheduling an outpatient procedure.
B. The patient's dietary preferences: Dietary preferences are usually relevant for specific procedures that require dietary modifications but are not generally necessary for the scheduling process.
C. The patient's demographic information: Demographic information such as the patient's name, date of birth, and contact details are necessary for scheduling and for identifying and contacting the patient.
D. A copy of the patient's advance directives: Advance directives are important for treatment decisions but are not required for scheduling outpatient procedures.