Documentation/Records

Question 1

CC

Answer 1

Chief complaint and is the same as Subjective in the SOAP format.

Question 2

Px

Answer 2

Physical examination and is the same as Objective in the SOAP format

Question 3

Dx

Answer 3

Diagnosis and is the same as Assessment in the SOAP format.

Question 4

Rx

Answer 4

Prescription and is the same as Plan in the SOAP format.

Question 5

AHIMA

Answer 5

American Health Management Association- association for healthcare professionals that provides a list of documentation guidelines.-

Question 6

Good Record keeping practices- 5

Answer 6

legible, understandable, timely, error free, reproductible

Question 7

Addendum

Answer 7

s the addition of information that was left out of the original entry

Question 8

Amendment

Answer 8

To add clarification or missing details from an initial documentation

Question 9

Discrete Data

Answer 9

information that consists of separate and limited values, such as distinct points on a numeric scale, with distinct intervals between any two values

Question 10

Quantifiable

Answer 10

which can be determined, indicated or expressed

Question 11

HIE

Answer 11

Health Information Exchange-allows healthcare professionals and patients to appropriately access and securely share a patient’s medical information electronically

Question 12

CPR

Answer 12

Computer based patient record-an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data

Question 13

CPOE

Answer 13

Computerized provider order entry
a system in which provider directly enter medication orders, tests and procedures electronically,

Question 14

Interoperability

Answer 14

the ability for different electronic record software to communicate among multiple machines

Question 15

Controlled Vocabulary

Answer 15

means that a specific set of terms in the electronic record’s data dictionary must be used.

Question 16

SNOMED CT

Answer 16

Systematized Nomenclature of Medicine - Clinical Terms presents data in a completely machine-readable format.

Question 17

LOINC

Answer 17

Logical Observation Identifiers Names and Codes

Question 18

RxNorm

Answer 18

Federal Drug Terminolgy

Question 19

PHR

Answer 19

personal health record which is medical information that the patient maintains

Question 20

EDMS

Answer 20

electronic data management system have implemented a hybrid medical records system Such systems use standard word-processed documents in conjunction with the electronic record

Question 21

CMS-1500

Answer 21

is the standard claim form used to request payment for services rendered by the healthcare provider.

Question 22

UB-04

Answer 22

The UB-04, also known as the CMS-1450, is the uniform claim form used in hospitals and other inpatient settings

Question 23

CPT

Answer 23

Current Procedural Terminology contains codes that describe the procedures and services performed by the provider for outpatient services.

Question 24

HCPCS Level II codes

Answer 24

5 digit alphanumeric. Not in CPT
These codes include drugs, durable medical equipment, ambulance services and prosthetic procedures.

Question 25

ICD-10-CM

Answer 25

diagnostic codes for both inpatient and outpatient services. The ICD-10-CM is an alphanumeric classification system. A valid code may be between three and seven characters, with a decimal after the third character.

Question 26

ICD-10-PCS

Answer 26

inpatient procedures.

7 digit. Numbers and All letters except I and O. No decimal