Chapter 2 EHRs, HIPPA, & HITECH

Question 1

File containing the documentation of a patient’s medical history and related information

Answer 1

medical record

Question 2

Failure to use professional skill when giving medical services that results in injury or harm

Answer 2

malpractice

Question 3

Recording of a patient’s health status in a medical record

Answer 3

documentation

Question 4

State-specific performance measures for the delivery of healthcare

Answer 4

medical standards of care

Question 5

Computerized lifelong healthcare records for an individual that incorporate date from all sources that treat an individual

Answer 5

Electronic health records (EHRs)

Question 6

Computerized records of one physician’s encounters with a patient over time that are the physician’s legal record of patient care.

Answer 6

Electronic medical records (EMRs)

Question 7

Private, secure electronic files that are created, maintained, and controlled by patients

Answer 7

Personal health records (PHRs)

Question 8

Advantages of EHRs

Answer 8

1. Immediate access to health information
2. Computerized physician order entry management
3. Clinical decision support
4. Automated alerts and reminders
5. Electronic communication and connectivity
6. Patient support
7. Administration and reporting
8. Error reduction.

Question 9

Visit between a patient and a medical professional

Answer 9

encounter

Question 10

Provider’s evaluation of a patient’s condition and decision on a course of treatment to manage it

Answer 10

evaluation and management (E/M)

Question 11

H & P documentation includes 4 types of info:

Answer 11

1. The chief complaint
2. the H&P examination
3. the diagnosis
4. the treatment plan

Question 12

Process by which a patient authorizes medical treatment after a discussion with a physician

Answer 12

informed consent

Question 13

3 other types of chart notes

Answer 13

1. Progress Notes
2. Discharge summary
3. Procedural services documentation

Question 14

Circle that explains how using EHRs is integrated with practice management programs

Answer 14

medical documentation and revenue cycle

Question 15

CC

Answer 15

Chief complaint

Question 16

Federal agency that runs Medicare, Medicaid, clinical laboratories, and other government health programs

Answer 16

Centers for Medicare and Medicaid Services (CMS)

Question 17

What department is CMS a part of?

Answer 17

The Department of Health and Human Services (HHS)

Question 18

Federal Act with guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse, and protecting PHI

Answer 18

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Question 19

Law promoting the adoption and meaningful use of health information technology

Answer 19

Health Information Technology for Economic and Clinical Health Act (HITECH)

Question 20

Utilization of certified EHR technology to improve quality, efficiency, and patient safety

Answer 20

meaningful use

Question 21

Enables the sharing of health-related information among provider organizations

Answer 21

health information exchange (HIE)

Question 22

Health system reform legislation that offers improved insurance coverage and other benefits

Answer 22

Affordable Care Act (ACA)

Question 23

Network of doctors and hospitals that shares responsibility for managing the quality and cost of care provided to a group of patients

Answer 23

accountable care organization (ACO)

Question 24

Computer-to-computer exchange of data in a standardized format

Answer 24

electronic data interchange (EDI)

Question 25

Electronic exchange of healthcare information

Answer 25

transaction

Question 26

3 parts of the Administrative Simplification provisions

Answer 26

1. HIPAA Privacy Rule 2. HIPAA Security Rule 3. HIPAA Electronic Transaction and Code Sets Standards

Question 27

Health plan, clearinghouse, or provider who transmits any health information in electronic form

Answer 27

covered entity (CE)

Question 28

Company that converts nonstandard transactions into standard transactions and transmits the data to health plans, and the reverse process

Answer 28

clearinghouse

Question 29

Person or organization that performs a function or activity for a covered entity

Answer 29

business associate (BA)

Question 30

Law regulating the use and disclosure of patients' protected health information

Answer 30

HIPAA Privacy Rule

Question 31

Individually identifiable health information transmitted or maintained by electronic media

Answer 31

protected health information (PHI)

Question 32

Legitimate reason for the sharing of patients' protected health information without authorization

Answer 32

treatment, payment, and healthcare operation (TPO)

Question 33

Principle that individually identifiable health information should be disclosed only to the extent needed

Answer 33

minimum necessary standard

Question 34

Covered entity's records that contain protected health information; for providers, the medical/financial patient record

Answer 34

designated record set (DRS)

Question 35

Description of a covered entity's principles and procedures related to the protection of patient's health information

Answer 35

Notice of Privacy Practices (NPP)

Question 36

Documentation of the disclosure of a patient's PHI in that person's medical record in unauthorized cases

Answer 36

accounting of disclosure

Question 37

1. Document signed by a patient to permit release of medical information; 2. health plan's system of approving payment of benefits for appropriate services

Answer 37

authorization

Question 38

Medical data from which individual identifiers have been removed

Answer 38

de-identified health information

Question 39

Law requiring covered entities to establish safeguards to protect health information

Answer 39

HIPAA Security Rule

Question 40

Method of converting a message into encoded text

Answer 40

encryption

Question 41

Confidential authentication information

Answer 41

password

Question 42

Impermissible use or disclosure of PHI that could pose significant risk to the affected person

Answer 42

breach

Question 43

Document notifying an individual of a breach

Answer 43

breach notification

Question 44

Rule governing the electronic exchange of health information

Answer 44

HIPAA Electronic Health Care Transactions and Code Sets (TCS)

Question 45

Rules that improve interoperability between the data systems of different entities

Answer 45

operating rules

Question 46

Alphabetic and/or numeric representations for data

Answer 46

code set

Question 47

Identification systems for employers, healthcare providers, health plans, and patients

Answer 47

HIPAA National Identifiers

Question 48

Unique ten-digit identifier assigned to each provider

Answer 48

National Provider Indentifier (NPI)

Question 49

Set of regulations enhancing patients' privacy protections and rights to information and the government's ability to enforce HIPAA

Answer 49

Omnibus Rule

Question 50

Government agency that enforces the HIPAA Privacy Act

Answer 50

Office for Civil Rights (OCR)

Question 51

Part of CMS that helps to develop and coordinate the implementation of a comprehensive e-health strategy

Answer 51

Office of E-health Standards and Services (OESS)

Question 52

Formal examination of a physician's or a payer's records

Answer 52

audit

Question 53

Government program to uncover and prosecute fraud and abuse in federal healthcare programs

Answer 53

Health Care Fraud and Abuse Control Program

Question 54

Government agency that investigates and prosecutes fraud

Answer 54

Office of the Inspector General (OIG)

Question 55

Person who makes an accusation of fraud or abuse

Answer 55

relator

Question 56

Intentional deceptive act to obtain benefit by taking advantage of another person

Answer 56

fraud

Question 57

Action that improperly uses another's resources

Answer 57

abuse

Question 58

A medical practices written plan for complying with regulations

Answer 58

compliance plan