CBCS Coding Exam Flashcards
A health record is derived from
1st medical treatment
What is health record?
Written information about patient collected from varies medical sorts
In the context do medical legal, what is the main record?
Unbiased opinion about patient conditions
How many health record should be kept on each patient
One
In a source oriented medical record the information about a patients care and illness is typically organized accounting to
Source & Chronological
What is flow sheet for?
The patient progress
Flow sheets are often used with what kind of health record
Source oriented
Progress notes are in what format
Flow sheets
Healthcare location and setting information is typically capture by
SYNOPSIS and preexisting pre established
What the most common form of database used in health care industry?
Rational Data base
What is a warehouse?
Central accessible location
What is the foundation do every health database system
TABLE
A master table has a list of variable that represent
The range of attributes
What refers to one or more data attributes that uniquely identify an entity?
Primary key - PK
In the US what often being considered for use as the choice patient identifier?
SS
The health care financing administration HCFA has produce a popular provider identifier known as
UPIN - Universal physician identifier pin
The health industry number HIN was issued by. The health industry business communications council HIBCC to serve as
Identifier for health facilities , retail, pharmacies, physical
The labeled identification code LIC is issued by HIBCC for identifying
Manufacturer or distributors
The universal product code (UPC) is maintain by the uniform code council for
Retail Product sold
The responsibility for the accuracy and completeness of a health record rests with
The attending doctor
What plays a strategic role I providing access to computerized health information
Clinical vocabularies
Standard vocabularies are a means a of
Encoding data for exchange
The joint commission on the accreditation of Healthcare Organizations (JCAHO) sets stand for
Health care organizations
The health Information and Management Systems Society (HIMSS) is a membership organization which focuses on advocating
Optimal use of healthcare information technology
What is medicare
Federal health insurance program for the elderly
Medicare has how many parts
4 parts - A&B - Hospital & Medical
C&D - Flexibility prescriptions
What is Tricare
Military healthcare for families
Primary care refers to
Principle point of consultation of patient
Secondary care refers to
Specialize not first contact of patient
Tertiary care refers to
Specialize with equipment in office for advance investrgation
Quaternary care is an extension of
Tertiary care
Define Electronic Health Record
Patient health record generated at an medical facility
The ASTM standard ________ outlines practice for Content and Structure of the EHR
E1384
__________ is a specific kind of digital medical record intended to be easily transported
Ambulatory
Compare EMRs with EHRs
Computerize vs Shared Records with other medical & government clinic records
What is Clinical data repository
Real time transactions
What is HL7 for
Health related data exchange in (North America)
What is the preeminent healthcare IT standards developing organization in Europe
CENTC 215
HCPCS Codes are in fact based on what codes
CPT Codes
HCPCS Level I codes are identical to what codes
CPT Codes
HCPCS Level II codes are used mostly by
Medical supplier and equipment
The In tern atonal Classification of Disease ICD is published by
WHO - World Health Organization
The ICD CM (Clinical Modification) is developed by
national Center of Health Statices
The ICD CM has the purpose of
Classifying mobility from patient records
The ICD Provides a format for reporting cause
Of death on death certificate
At the time a patient presents with an un diagnosed illness the ICD-9 code would be determined by
Signs & Systems
Definitive ICD-9 codes should NOT be assigned and recorded in the medical record UNTIL AFTER
Diagnosis is determined
The ICF (International Classification of Functioning Disability and Health) classification is in a position to complement
The ICD-10
The language of the ICF is said to be made neutral as to etiology thus placing the emphasis
On function NOT Condition or Disease
Systematized Nomenclature of Medicine (SNOMED) is developed by
SNOMED INTERNATIONAL PART OF American Pathologists College (CAP)
SNOMED is created for the indexing of
For medical records in a comprehensive, multi-axial and control terminology
SNOMED (systematized Nomenclature of Medicine) CT (Clinical Terms) aims at specifying
Core file structure of SNOMED CT (clinical terms)
Prospective payment system (PPS) are indexed to
Motivate providers to deliver patient care more effectively & efficiently
