ITHS Chapter 3 Flashcards
Fundamental Skills in Health Informatics
What is the act of sharing a message, thought, or idea so that it is accurately received and understood?
communication
What refers to the appropriate conduct, etiquette, or procedures for communication?
protocol
What is the response of an audience to a message?
feedback
What is the nonverbal communication that occurs through conscious or unconscious gestures and movements?
body language
What is the file that contains documents that describe a specific patient’s medical history and medical care within one healthcare organization and is also known as a chart or a file?
medical record
What is the patient’s reason for seeing a physician called?
the chief complaint
What includes all possible problems to be ruled out to identify the correct diagnosis?
differential diagnosis
What does SOAP stand for?
subjective, objective, assessment, plan
What is the common paper-based system for organizing information in a medical record?
source-oriented medical record (SOMR)
What is the record organized according to the patient’s problem?
Problem-oriented medical record (POMR)
What are the written reports of observable, measureable, and reproducible findings from examinations, which support laboratory diagnostic tests?
medical documentation
What is the process of recording observations and information about patients?
charting
What are the guidelines that are to be followed?
compliance
What is the evaluation process in which a group of patients are sorted according to the urgency of their need for care?
triage
What is a person’s ability to obtain and understand what their health needs are?
health literacy
What is the medical document that contains information from all of the clinicians involved in a patient’s care and which can be created and managed by authorized clinicians and staff across more than one organization?
Electronic health record (EHR)
What is the private system that can’t communicate with other records systems?
proprietary
What records contain a standardized summary of the most relevant and timely health information about a patient?
continuity of care records (CCRs)
What records invite patients to participate in their health management?
personal health records (PHRs)
What is the machine used to transmit pictures or written documents using the public telephone network?
facsimile machines/fax machines
What are the facts about a specific topic that are used for reference or analysis?
data
What is the term for the science that includes the collection, organization, and interpretation of numerical data?
statistics
What are the procedures for submitting costs for medical services so that payment can be collected or denial can be determined?
claims process
What is the process when adult patients and the person carrying signs the claim form allowing payments to be made directly to the medical office and granting permission to release medical information to the insurance company?
assignment of benefits
What is the detailed account of each claim processed by an insurance plan, which is sent to the patient as notification of claim payment or denial?
explanation of benefits (EOB)
What are the out-of-pocket fees paid by a person with health insurance at the time a covered service, such as an office visit or a prescription, is received?
copays
