Ch 10 - Medical Records

Question 1

Active patient files

Answer 1

Files of patients who are being actively seen within the specific healthcare facility.

Question 2

CHEDDAR

Answer 2

A type of organization of medical record documentation that breaks down information into chief complaint, history, examination, details, drugs, assessment, and return visit plan.

Question 3

Chief complaint (CC)

Answer 3

A specific reason the patient is being seen by the healthcare provider.

Question 4

Clearinghouses

Answer 4

Entities that processes electronic transactions into HIPAA standardized transactions for billing submission.

Question 5

Closed-ended questions

Answer 5

Types of questions that can be answered by a simple “yes” or “no.”

Question 6

Confidentiality

Answer 6

Keeping private all personal information regarding the patient.

Question 7

Continuity of care record (CCR)

Answer 7

A patient’s medical health record that is accurate to ensure continuity of care when a patient is transferred to another healthcare provider or to a medical specialist.

Question 8

Covered entity (CE)

Answer 8

Health plans, healthcare clearinghouses, and healthcare providers under HIPAA who electronically transmit any health information.

Question 9

Differential diagnosis

Answer 9

A list of possible diagnoses that may likely be the cause of the presenting symptoms.

Question 10

Double lock system

Answer 10

A safeguard that requires passing through two systems of security to access any confidential patient information.

Question 11

Electronic medical record (EMR) and electronic health records (EHR)

Answer 11

Electronic medical records that contain medical and health records of individual patients, maintaining the HIPAA standards for privacy and security.

Question 12

Firewalls

Answer 12

Network security devices that monitors incoming and outgoing network traffic and decides whether to allow or block specific traffic based on a defined set of security rules.

Question 13

Fraud

Answer 13

Wrongful or criminal deception intended to result in financial or personal gain.

Question 14

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Answer 14

Federal legislation that provides data privacy and security provisions for safeguarding medical information.

Question 15

Inactive patient files

Answer 15

Files of patients who have not been seen within the specific healthcare facility over the preceding 3 years.

Question 16

Liability

Answer 16

Legal responsibility and accountability for all health and financial patient care.

Question 17

Malpractice

Answer 17

Improper, illegal, or negligent professional activity or treatment by a medical practitioner.

Question 18

Open-ended questions

Answer 18

Types of questions that require more thought and more than a simple one-word answer.

Question 19

Protected health information (PHI)

Answer 19

Any information about a patient’s health status, provision of healthcare, or payment for healthcare that is created or collected by a covered entity (or a business associate of a covered entity), and can be linked to a specific individual.

Question 20

SOAP

Answer 20

An acronym used to document in patient’s medical chart meaning: Subjective, Objective, Assessment, and Plan.

Question 21

Statutes of limitations

Answer 21

A law that sets out the maximum time that parties must initiate legal proceedings from the date of an alleged offense.