Documentation and Record Keeping Flashcards

Under HIPAA, which disclosure of PHI is exempt from the 'minimum necessary' standard?

Answer: Disclosure to a healthcare provider for treatment purposes

The minimum necessary rule does not apply to disclosures to providers for treatment, so clinicians can share the full information needed for care.

A patient asks for a copy of their diabetes education records. Under HIPAA, generally how long does the covered entity have to act on the request?

Answer: 30 days, with one possible 30-day extension

HIPAA requires action on access requests within 30 days, with a single 30-day extension allowed if the patient is notified in writing.

Which element is especially important to document for a DSMES telehealth visit?

Answer: The telehealth modality (audio-video or audio-only), the patient's location, and consent

Billing and compliance rules for telehealth depend on the modality, the patient's location, and documented consent.

Which documented behavioral goal best meets SMART criteria?

Answer: Walk 20 minutes after dinner 5 days a week for the next 4 weeks

This goal is specific, measurable, achievable, relevant, and has a time frame.

According to the National Standards for DSMES, which must be documented in the participant's record?

Answer: Individualized assessment, education plan, self-management goals, and progress or outcomes

The Standards require documenting the person-centered assessment, the plan, the education delivered, and goal or outcome evaluation.

After the initial year, how much follow-up DSMT does Medicare cover each calendar year?

Answer: 2 hours

Medicare covers 2 hours of follow-up DSMT per calendar year after the initial benefit.

When documenting CGM data for most nonpregnant adults with diabetes, what time-in-range goal (70-180 mg/dL) is recommended by international consensus?

Answer: Greater than 70%

Consensus targets are TIR above 70% with time below 70 mg/dL under 4%.