Describe why an addendum should be used in a medical record
?Addenda should be used when information in a person's record is incorrect. By retaining the original form and including an addendum, legal questions about a change should be reduced. An addendum should include the date, time, reason for the change, and the signature of the person entering the addendum, followed by professional credentials such as MD, RN, or other.
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You are called to the scene of a 55-year-old woman lying on the side of the road. There are no bystanders present. You determine that she is unresponsive. You should next:
A) check if the patient is unconscious. B) open her airway with a head-tilt/chin-lift maneuver. C) open her airway with a jaw-thrust maneuver. D) call for additional assistance.
Because WC cases may be reviewed by the courts, it is important that the medical record include:
a. all of the patient's medical history. b. no names of any kind. c. all conversations with the patient, employer, and WC insurance agency. d. diagnostic information.
In the initial assessment, one of the first steps after checking the scene for safety purposes and donning BSI is to establish and maintain head and neck stabilization if the patient is unconscious or a traumatic injury is suspected.
Answer the following statement true (T) or false (F)
Biometric information, including fingerprints and voiceprints are included as PHI under HIPAA
a. True b. False