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Understanding Health Insurance > Chapter 2 EHRs, HIPPA, & HITECH > Flashcards

Chapter 2 EHRs, HIPPA, & HITECH Flashcards

1
Q

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

A

medical record

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2
Q

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

A

malpractice

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3
Q

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

A

documentation

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4
Q

State-specific performance measures for the delivery of healthcare

A

medical standards of care

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5
Q

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

A

Electronic health records (EHRs)

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6
Q

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

A

Electronic medical records (EMRs)

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7
Q

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

A

Personal health records (PHRs)

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8
Q

Advantages of EHRs

A
  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.
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9
Q

Visit between a patient and a medical professional

A

encounter

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10
Q

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

A

evaluation and management (E/M)

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11
Q

H & P documentation includes 4 types of info:

A
  1. The chief complaint
  2. the H&P examination
  3. the diagnosis
  4. the treatment plan
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12
Q

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

A

informed consent

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13
Q

3 other types of chart notes

A
  1. Progress Notes
  2. Discharge summary
  3. Procedural services documentation
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14
Q

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

A

medical documentation and revenue cycle

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15
Q

CC

A

Chief complaint

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16
Q

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

A

Centers for Medicare and Medicaid Services (CMS)

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17
Q

What department is CMS a part of?

A

The Department of Health and Human Services (HHS)

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18
Q

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

A

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

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19
Q

Law promoting the adoption and meaningful use of health information technology

A

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

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20
Q

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

A

meaningful use

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21
Q

Enables the sharing of health-related information among provider organizations

A

health information exchange (HIE)

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22
Q

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

A

Affordable Care Act (ACA)

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23
Q

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

A

accountable care organization (ACO)

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24
Q

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

A

electronic data interchange (EDI)

25
Q

Electronic exchange of healthcare information

A

transaction

26
Q

3 parts of the Administrative Simplification provisions

A
  1. HIPAA Privacy Rule
  2. HIPAA Security Rule
  3. HIPAA Electronic Transaction and Code Sets Standards
27
Q

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

A

covered entity (CE)

28
Q

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

A

clearinghouse

29
Q

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

A

business associate (BA)

30
Q

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

A

HIPAA Privacy Rule

31
Q

Individually identifiable health information transmitted or maintained by electronic media

A

protected health information (PHI)

32
Q

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

A

treatment, payment, and healthcare operation (TPO)

33
Q

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

A

minimum necessary standard

34
Q

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

A

designated record set (DRS)

35
Q

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

A

Notice of Privacy Practices (NPP)

36
Q

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

A

accounting of disclosure

37
Q
  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
A

authorization

38
Q

Medical data from which individual identifiers have been removed

A

de-identified health information

39
Q

Law requiring covered entities to establish safeguards to protect health information

A

HIPAA Security Rule

40
Q

Method of converting a message into encoded text

A

encryption

41
Q

Confidential authentication information

A

password

42
Q

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

A

breach

43
Q

Document notifying an individual of a breach

A

breach notification

44
Q

Rule governing the electronic exchange of health information

A

HIPAA Electronic Health Care Transactions and Code Sets (TCS)

45
Q

Rules that improve interoperability between the data systems of different entities

A

operating rules

46
Q

Alphabetic and/or numeric representations for data

A

code set

47
Q

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

A

HIPAA National Identifiers

48
Q

Unique ten-digit identifier assigned to each provider

A

National Provider Indentifier (NPI)

49
Q

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

A

Omnibus Rule

50
Q

Government agency that enforces the HIPAA Privacy Act

A

Office for Civil Rights (OCR)

51
Q

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

A

Office of E-health Standards and Services (OESS)

52
Q

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

A

audit

53
Q

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

A

Health Care Fraud and Abuse Control Program

54
Q

Government agency that investigates and prosecutes fraud

A

Office of the Inspector General (OIG)

55
Q

Person who makes an accusation of fraud or abuse

A

relator

56
Q

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

A

fraud

57
Q

Action that improperly uses another’s resources

A

abuse

58
Q

A medical practices written plan for complying with regulations

A

compliance plan

Understanding Health Insurance (2 decks)

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