CHARTING

Question 1

reports created or programmed in response to an inquiry or issue that comes up; they are not normally scheduled reports

Answer 1

AD-HOC REPORTS

Question 2

compliance as it relates to paper or electronic medical records refers to the completion of the record and the adherence to medical records and documentation requirements set forth by state and federal law, as well as accreditation and regulatory agencies

Answer 2

COMPLIANCE

Question 3

reports run on records stored in a database to find specific information; an ad hoc report is set up as a query

Answer 3

DATABASE QUERIES

Question 4

assigned to inpatients based on the principal diagnosis; determines the hospital’s reimbursement; based on the prospective payment system

Answer 4

(DRGs) DIAGNOSIS-RELATED GROUPS

Question 5

refers to the fact that poor documentation or data entry results in poor output from a computer or information system

Answer 5

(GIGO) GARBAGE IN, GARBAGE OUT

Question 6

charts that are missing signatures, reports, or other required elements as outlined in either CMS Conditions for Participation for Medical Record Services or the Joint Commission accreditation guidelines for information management

Answer 6

INCOMPLETE CHARTS

Question 7

another word for insurance companies or the responsible party who will pay for the medical services patients receive; when patients do not have insurance, the payer listed on the bill is self-pay

Answer 7

PAYERS

Question 8

the ability of providers to document the care and treatment they render in real time, when they are with the patient, it is made much easier with the use of clinical templates, digital dictation, point and click menus, and other technology solutions

Answer 8

(POC) POINT-OF-CARE CHARTING

Question 9

facilities that maintain records of any form must have a record destruction policy in place; an attorney should guide the development of any policy on records and consider state and federal laws, along with any regulatory and accreditation requirements

Answer 9

RECORD DESTRUCTION POLICY

Question 10

how long to retain medical records is a policy decision based on state and federal laws and regulatory and accreditation agency guidelines; an attorney should guide the development of any policy and consider facility needs that include patient characteristics, demographics, type of facility, and the availability of archived records and how that meets provider and patient needs

Answer 10

RECORD RETENTION

Question 11

storing data from your facility in more than one location so if one area is hit with a disaster event, the data is restored from a copy located elsewhere

Answer 11

REDUNDANT DATA STORAGE

Question 12

payment for services rendered; refers to the end result of the revenue cycle

Answer 12

REIMBURSEMENT

Question 13

five-step process that begins with providing services; after delivering services, provider document the care in the patient record, which drives the assignment of a code and establishes charges so a claim or bill can be prepared, submitted and eventually revenue received

Answer 13

REVENUE CYCLE

Question 14

intentional or unintentional assignment of a higher level code than the documentation supports

Answer 14

UP-CODING

Question 15

company or organization that sold a product or service to a facility; in EHR technology issues, EHR specialists should keep communications open with the vendor so they can work jointly to quickly resolve issues around software updates, hardware or software problems, or new functionality

Answer 15

VENDOR