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OTA 120: Documentation > Chapter 2 : The Health Record > Flashcards

Chapter 2 : The Health Record Flashcards

1
Q

What is a compilation of unique person and medical information relating to a client?

A

The medical record

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2
Q

The medical record is what type of document?

A

a legal document

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3
Q

What is the primary purpose of the health record?

A

the exchange of info among a client’s healthcare providers in order to determine problems, concerns, and strengths, plan and record treatment, substantiate care & fulfill legal documentation requirements

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4
Q

The health record is the property of……

A

the health care facility

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5
Q

HIPAA stands for……

A

Health Insurance Portability and Accountability Act (1996)

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6
Q

What does POMR stand for……

A

Problem Oriented Medical Record

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6
Q

What does POMR stand for……

A

Problem Oriented Medical Record

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7
Q

What is used by healthcare providers when submitting claims for reimbursement?

A

billing codes

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7
Q

What is used by healthcare providers when submitting claims for reimbursement?

A

billing codes

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8
Q

What type of code enables healthcare providers to use common language?

A

CPT codes

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8
Q

What type of code enables healthcare providers to use common language?

A

CPT codes

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9
Q

What are the 2 types of CPT codes?

A

1) Level I

2) Level II

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9
Q

What are the 2 types of CPT codes?

A

1) Level I

2) Level II

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10
Q

What type of code is a 5 digit code maintained by the AMA and based on procedures?

A

Level I Codes (CPT)

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10
Q

What type of code is a 5 digit code maintained by the AMA and based on procedures?

A

Level I Codes (CPT)

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11
Q

What type of code is a 1 letter and 4 digit codes for products and services such as DME, prosthetics?

A

Level II Codes (CPT)

11
Q

What type of code is a 1 letter and 4 digit codes for products and services such as DME, prosthetics?

A

Level II Codes (CPT)

12
Q

What does ICD stand for?

A

International Classification of Diseases

12
Q

What does ICD stand for?

A

International Classification of Diseases

13
Q

What type of codes are 3, 4 or 5 digit codes that classify diagnosis, symptoms or complaints?

13
Q

What type of codes are 3, 4 or 5 digit codes that classify diagnosis, symptoms or complaints?

14
Q

What does POMR stand for……

A

Problem Oriented Medical Record

15
Q

What is used by healthcare providers when submitting claims for reimbursement?

A

billing codes

16
Q

What type of code enables healthcare providers to use common language?

17
Q

What are the 2 types of CPT codes?

A

1) Level I

2) Level II

18
Q

What type of code is a 5 digit code maintained by the AMA and based on procedures?

A

Level I Codes (CPT)

19
Q

What type of code is a 1 letter and 4 digit codes for products and services such as DME, prosthetics?

A

Level II Codes (CPT)

20
Q

What does ICD stand for?

A

International Classification of Diseases

21
Q

What type of codes are 3, 4 or 5 digit codes that classify diagnosis, symptoms or complaints?

22
Q

What does POMR stand for……

A

Problem Oriented Medical Record

23
Q

What is used by healthcare providers when submitting claims for reimbursement?

A

billing codes

24
Q

What type of code enables healthcare providers to use common language?

25
Q

What are the 2 types of CPT codes?

A

1) Level I

2) Level II

26
Q

What type of code is a 5 digit code maintained by the AMA and based on procedures?

A

Level I Codes (CPT)

27
Q

What type of code is a 1 letter and 4 digit codes for products and services such as DME, prosthetics?

A

Level II Codes (CPT)

28
Q

What does ICD stand for?

A

International Classification of Diseases

29
Q

What type of codes are 3, 4 or 5 digit codes that classify diagnosis, symptoms or complaints?

OTA 120: Documentation (9 decks)

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