Chapter 10 medical terms Flashcards
Active patient files
Files of patients who are being actively seen within the specific health care facility
CHEDDAR
A type of organization of medical record documentation that breaks down information into chief complaint,history,examination, details,drugs, assessments and return visit plans
Chief complaint(CC)
a specific reason the patient is being seen by the health care provider
Clearinghouse
Entities that process electronic transactions into HIPAA standardized transaction for billing submission
Closed ended questions
types of questions that can be answered with a simple yes or no
Confidentiality
Keeping private all personal information regarding the patient
Continuity of Care record
A patients 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
Covered entity (HE)
Health plans, health care clearing houses and health care providers under HIPAA who electronically transmit any health information
Differential Diagnosis
A list of possible diagnosis that may likely be the cause of the presenting symptoms.
Double lock system
A safe award that requires passing through 2 systems of security to access any confidential patient information
Electronic medical records(EMR) or Electronic health records (EHR)
EMR’s contain medical and health records of individual patients, maintaining the HIPAA standards for privacy and security
Firewalls
Network security devices that monitor in and out going network traffic and decide whether to allow it to pass or be blocked. specific traffic based on a defined set of security rules.
Fraud
wrongful or criminal deception intended to result in financial or personal gain
Health Insurance Portability and Accountability Act of 1996(HIPAA)
Federal legislation that provides data privacy and security provisions for safe guarding medical information
Inactive patient files
Files of patients who have not been seen within the specific health care facility over the proceeding 3 years
Liability
legal responsibility and accountabililty for all health and financial patient care
Malpractice
Malpractice
Improper, illegal,or neglect professional activity or treatment by a medical practitioner
Open ended questions
types of questions that require more thought and more than a simple word answer
Protected Health Information(PHI)
Any information about a patients health status and provisions of health care or payment for healthcare that is created or selected by covered entity( or a business associate of a covered entity) and can be linked to a specific individual
SOAP
An acronym used to document in patients, medical chart meaning: subjective, objective, assessment and plan
Statutes of Limitations
A law that sets out the maximum time that parties must initiate legal proceedings from the date of an alleged offense
