Chii Chinosanganiswa
Chiremba rezvechiremba inyandiko yakarongeka yehutano hwehutano hwehutano uye kutarisirwa. Inowanzova nehutano hwehutano hwehutano (PHI) iyo inosanganisira ruzivo rwekuziva, nhoroondo yehutano, ruzivo rwekuongororwa kwezvoutano uye ruzivo rwekubhadhara.
Zvinyorwa zvechiremba zvakagara zvakachengetwa mupepeti, uye mabheji akaparadzanisa zvikamu. Sezvinyorwa zvinyorwa zvakagadzirwa, zvakasimudzirwa kune yakarurama tab. Nekuuya kwehuwandu hwehutachiona hwemagetsi , zvikamu izvi zvingave zvichiwanikwa asi semabato kana menyu mukati mehutori hwemagetsi.
Mwoyo Yevarwere
Shinda pepa, Fomu yekunyora :
- Zita revarwere
- Nhamba uye nhare dzefoni (kumba uye mobile)
- Chikero chetsamba yemumhepo
- Zvepabonde, Zera, Kuberekwa, uye Race (Ethnicity)
- Basa uye Mubhizimisi zita, kero, uye nhamba yefoni
- Mudzimai Zita uye mashoko ekukurukura
- Muchiitiko chekutsvaga tsvaga mashoko
Financial Information
- Inishuwarenzi zita rekubhadhara zita, kero uye nhamba yefoni
- Mubhalisi zita
- Nhamba yezano
- Inotarisira zita remukati, nhare uye nhamba yefoni
- Kutarisirwa kwekambani yevashandi, basa, uye nhare yefoni nhamba
- Ukama hukama nevhusi
Mvumo uye Mvumo yekupa Mvumo
Chibvumirano chekurapa : Chero nzira ipi zvayo yekurapa inopfuura chirongwa chekurapa nguva dzose, chiremba anofanira kuzivisa ruzivo rwakanyanya sezvinobvira kuitira murwere angaita chisarudzo chakanaka maererano nehanya kwake. Aya mashoko anofanira kusanganisira:
- Kuongororwa uye mikana yekudzikinura
- Yakarongwa nzira yekurapa
- Ngozi uye mhindu inobatanidzwa mukurapa
- Dambudziko kana pasina kurapwa kunotorwa
- Mikana yekubudirira kana kurapwa kutorwa
- Dambudziko rekudzorera nekureba kwenguva
Basa rokubatsira: murwere kana mutariri anopa kambani yavo yveshuwarhu yehutano inshumo yekubhadhara zvakananga kune chiremba, chiremba kana chipatara kune kurapa kwakagamuchirwa.
Kusunungurwa kwemashoko: Chibvumirano chakanaka chekusunungura mashoko ehutano akachengetedzwa chinosanganisira:
- Kuzivikanwa kwehuzivi hwekuzivikanwa sekuita seirivha yekutyaira.
- Tsanangudzo yezvinyorwa zvinofanira kushandiswa kana kuziviswa.
- Zita romunhu kana sangano rakagamuchirwa kuzivisa mashoko.
- Zita romunhu kana sangano iro ruzivo ruchazobudiswa.
- Chiratidzo cheiye munhu ane kodzero yekubudisa ruzivo.
Treatment History
- Chief complaints
- Nhoroondo yezvirwere
- Zvakakosha zviratidzo
- Kuongorora kwepanyama
- Histori yekuvhiya
- Nhoroondo yezvisizvo
- Kurapa kwechiremba
- Nhoroondo yemhuri
- Kuzvidzivirira nhoroondo
- Miitiro yakadai sekurovedza muviri, kudya, kunwa doro, kusvuta, uye kushandisa zvinodhaka / kushungurudzwa
- Developmental history
Nhamba dzekufambira mberi
Mafambiro ezvinyorwa anosanganisira ruzivo rutsva uye kuchinja munguva yekurapa kwechiremba. Izvo zvakanyorwa nhengo dzose dzeboka rerapa rekurapa. Zvimwe zvemashoko akabatanidzwa mukufambira mberi zvinosanganisira:
- Kuonekwa kwemuviri wehutano uye hwepfungwa
- Kamwe kamwe-kamwe kunochinja mamiriro ezvinhu emuurwere
- Zviratidzo zvinokosha pane dzimwe nguva
- Zvokudya zvinotora
- Chirwere uye maronda zvinoshanda
Mirayiridzo yechiremba uye Zvinyorwa
Chiremba wemirairo yemurwere kugamuchira kuongororwa, maitiro kana kuvhiyiwa kunosanganisira mazano kune dzimwe nhengo dzeboka rekurapa.
Zvinyorwa zvemishonga nemishonga yezvokurapa kana midziyo yevarwere kushandiswa kwemusha.
Ongororo
Zvitsva uye maonero kubva kuvanachiremba.
Lab Reports
Nhoroondo yezvinowanikwa kubva kubasa rekuongorora.
Rediology Reports
Nhoroondo yezvakawanikwa kubva kudiviology yekuedzwa.
Notes Nursing
Vanamukoti manotsi vanosanganisira mabhuku akaparadzaniswa nachiremba anosanganisira:
- Mwoyo murefu
- Maitiro
- Kupindira
- Kuongorora
Mishonga Inoratidzira
Mishonga yemishonga uye isiriprescription kusanganisira nhamba, nzira yekudya, uye purogiramu.
HIPAA Chinyorwa Chekuita Zvisina Kuita Maitiro
Ichi chinocherechedza, sezvinodiwa neHIPAA Privacy Rule , inopa varwere kodzero yekutaurirwa pamusoro pekodzero dzavo dzepachivande sezvazviri maererano nehupenyu hwavo hwakachengetedzwa hwehutano (PHI).
Imwe hofisi yezvokurapa ine mutoro kuvarwere vavo nemutemo wehurumende kuchengetedza hupenyu hwehutano hwavo hunoga uye huchengeteka. Zvinyorwa zvinogadziriswa maererano nehutano hwehutano hwakachengetedzwa pasina hurumende inonzi inopesana neChinyorwa Chekuita pasi peHIPAA. Kunyanya kuvhiringidzika kwepachivande hakuiti nekuda kwechinangwa chinonyangadza asi kune ngozi kana kusaregerera pane chikamu chesangano.
- Ita chirongwa chekuchengetedza chirongwa chekuchengetedza kusanganisira kushandiswa kwemitemo nemitemo, kuongorora kweperi, chirongwa chekugadziriswa uye zvimwe zvidziviriro zvekuita kuti vateereri vehofisi vezvehutano vabvumirwe.
- Ita mazano ekusimbisa zvibvumirano zvekugamuchira, kugadziriswa kwemichina, uye kubata vatenzi.
- Kuvandudza uye kupa magwaro kunosanganisira mirayiridzo yekuti iwe hofisi yezvechiremba inogona kubatsira sei kuchengetedza PHI (somuenzaniso, kuvhara kombiyuta isati yaisiya isina kutarisirwa).
- Gadzira chiziviso chakasiyana-siyana chemushandisi kusanganisira passwords uye nhamba dzepini.