Ethics and HIPAA Flashcards
medical record
A file that contains the documentation of a patient’s medical history, record of care, progress notes, correspondence, and related billing/financial information.
documentation
The systematic, logical, and consistent recording of a patient’s health status—history, examinations, tests, results of treatments, and observations—in chronological order in a patient medical record.
medical standards of care
State-specified performance measures for the delivery of healthcare by medical professionals.
evaluation and management (E/M)
Provider’s evaluation of a patient’s condition and decision on a course of treatment to manage it.
informed consent
The process by which a patient authorizes medical treatment after discussion about the nature, indications, benefits, and risks of a treatment a physician recommends.
21st Century Cures Act
A federal law that requires providers to make certain specific categories of clinical notes digitally accessible to patients.
medical documentation and revenue cycle
A series of steps that explain how using EHRs is integrated with practice management programs as the 10-step billing process is formed.
Centers for Medicare and Medicaid Services (CMS)
Federal agency within the Department of Health and Human Services (HHS) that runs Medicare, Medicaid, clinical laboratories (under the CLIA program), and other government health programs.
Health Insurance Portability and Accountability Act (HIPAA) of 1996
Federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.
Health Information Technology for Economic and Clinical Health (HITECH) Act
Law that guides the use of federal stimulus money to promote the adoption and meaningful use of health information technology, mainly using electronic health records.
meaningful use
The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system.
Affordable Care Act (ACA)
Health system reform legislation that offers improved insurance coverage and other benefits.
accountable care organization (ACO)
A network of doctors and hospitals that shares responsibility for managing the quality and cost of care provided to a group of patients.
electronic data interchange (EDI)
The system-to-system exchange of data in a standardized format.
business associate (BA)
A person or organization that performs a function or activity for a covered entity but is not part of its workforce.
