Chapter 10 medical terms

Question 1

Active patient files

Answer 1

Files of patients who are being actively seen within the specific health care 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, assessments and return visit plans

Question 3

Chief complaint(CC)

Answer 3

a specific reason the patient is being seen by the health care provider

Question 4

Clearinghouse

Answer 4

Entities that process electronic transactions into HIPAA standardized transaction for billing submission

Question 5

Closed ended questions

Answer 5

types of questions that can be answered with a simple yes or no

Question 6

Confidentiality

Answer 6

Keeping private all personal information regarding the patient

Question 7

Continuity of Care record

Answer 7

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

Question 8

Covered entity (HE)

Answer 8

Health plans, health care clearing houses and health care providers under HIPAA who electronically transmit any health information

Question 9

Differential Diagnosis

Answer 9

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

Question 10

Double lock system

Answer 10

A safe award that requires passing through 2 systems of security to access any confidential patient information

Question 11

Electronic medical records(EMR) or Electronic health records (EHR)

Answer 11

EMR’s 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 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.

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 safe guarding medical information

Question 15

Inactive patient files

Answer 15

Files of patients who have not been seen within the specific health care facility over the proceeding 3 years

Question 16

Liability

Answer 16

legal responsibility and accountabililty for all health and financial patient care

Question 17

Malpractice

Question 18

Malpractice

Answer 18

Improper, illegal,or neglect professional activity or treatment by a medical practitioner

Question 19

Open ended questions

Answer 19

types of questions that require more thought and more than a simple word answer

Question 20

Protected Health Information(PHI)

Answer 20

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

Question 21

SOAP

Answer 21

An acronym used to document in patients, medical chart meaning: subjective, objective, assessment and plan

Question 22

Statutes of Limitations

Answer 22

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