Health Clinical Exam #1 Flashcards
Interoperability
The ability of software or systems to make use of information and exchange with other providers, facilities, etc.
Point of Care
Occurs at time patient is being seen, through speech or voice recognition. It is like taking notes while listening to the patient.
Duplicate patient registration entries
Each patient is only entered ONCE in a hospital or facility.
Database
Allows for documentation in clinical and administrative data on one platform. This results in better coordination of care for the patient and allows concentration on patient care. Also known as patient list.
Master Patient Index
Permanent listing of all patients who have received care in hospital setting, in patient or outpatient. This prevents duplication of records. You are also able to pull this up by social
Encounter
How many times you have been to the establishment
Clinical providers cost increases for EHRs-
Hardware and equipment can be costly. Also, training on software and planning for implementation can be costly.
Service providers cost increases for EHRs
These are who are paying for research and development of products so it is very costly. It cost more than it does for clinical providers.
What are the 3 covered entities?
Health Plans, Health Care Clearing Houses, Health Care Providers
Health Plans
Usually a group plan that pays for or provides medical care.
Health Care Clearing Houses
A public or private entity that processes patient data into a standardized billing format and checks for inconsistencies or errors in that data.
Health Care Providers
The provider of medical or health services.
Clinical Functions:
Includes information like chief complaint, vital signs, physical exams and pt history. This is patient medical information and is very important.
Financial Functions:
Complete billing claim form and sending insurance claims to correct insurance company.
Administrative Functions:
Filing claims, revenue management, collecting patient demographics.
Clinical and Administrative functions are:
Reported separately in patient records.
Registration:
The process of getting to know the patient. In a clinical setting, it can be done either through a registration form or verbally. The health provider may ask or even fill out a form for: name, social, DOB, marital status, race, insurance, etc., to get to know the patient before proceeding to the scheduling process.
Admission:
Known as approving a patient into the healthcare facility. In a clinical setting, sometimes registration determines if a patient is admitted. However, if they are admitted, they can get the treatment they need.
Discharge:
Is known as the patient leaving the healthcare facility once treated. In a clinical setting once the patient is treated, patients go home with additional information of their treatment such as a pamphlet or notes. This is important to ensure the treatment process is going well.
Transfer
The process when a patient might have to move to another healthcare facility. In a clinical setting, there may be times that doctors/nurses might need another sample or need to have additional labs run to figure out the problem, so patients might be transferred to a different department.
National Providers Identifier (NPI) number
Usually 10 digits that is used on insurance claims to let the insurance know who rendered care to the patient. This number is also issued out by the Centers for Medicare & Medicaid services. Used in a clinical setting when filling out the insurance claim.
National Health Information Network
Also know as NHIN, is policies, service, and standards that secures the exchange of HI. This is used in a clinical setting as healthcare workers must exchange patients’ data over the internet.
HIPAA:
Also known as the Health Insurance Portability and Accountability Act, is an act that is used in HI to protect and secure patient information. It also helps people who lost their job to find another insurance or keep their insurance with a pre-existing condition. This act is very important because in healthcare, confidentiality and privacy of patient information is a big part of healthcare.
Office of the National Coordinator (OCR)
An entity in charge of the implementation, coordination, and use of HIT and HIE. Supports the promotion of HIT nationwide.
