ITHS Chapter 3

Question 1

What is the act of sharing a message, thought, or idea so that it is accurately received and understood?

Answer 1

communication

Question 2

What refers to the appropriate conduct, etiquette, or procedures for communication?

Answer 2

protocol

Question 3

What is the response of an audience to a message?

Answer 3

feedback

Question 4

What is the nonverbal communication that occurs through conscious or unconscious gestures and movements?

Answer 4

body language

Question 5

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?

Answer 5

medical record

Question 6

What is the patient’s reason for seeing a physician called?

Answer 6

the chief complaint

Question 7

What includes all possible problems to be ruled out to identify the correct diagnosis?

Answer 7

differential diagnosis

Question 8

What does SOAP stand for?

Answer 8

subjective, objective, assessment, plan

Question 9

What is the common paper-based system for organizing information in a medical record?

Answer 9

source-oriented medical record (SOMR)

Question 10

What is the record organized according to the patient’s problem?

Answer 10

Problem-oriented medical record (POMR)

Question 11

What are the written reports of observable, measureable, and reproducible findings from examinations, which support laboratory diagnostic tests?

Answer 11

medical documentation

Question 12

What is the process of recording observations and information about patients?

Answer 12

charting

Question 13

What are the guidelines that are to be followed?

Answer 13

compliance

Question 14

What is the evaluation process in which a group of patients are sorted according to the urgency of their need for care?

Answer 14

triage

Question 15

What is a person’s ability to obtain and understand what their health needs are?

Answer 15

health literacy

Question 16

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?

Answer 16

Electronic health record (EHR)

Question 17

What is the private system that can’t communicate with other records systems?

Answer 17

proprietary

Question 18

What records contain a standardized summary of the most relevant and timely health information about a patient?

Answer 18

continuity of care records (CCRs)

Question 19

What records invite patients to participate in their health management?

Answer 19

personal health records (PHRs)

Question 20

What is the machine used to transmit pictures or written documents using the public telephone network?

Answer 20

facsimile machines/fax machines

Question 21

What are the facts about a specific topic that are used for reference or analysis?

Answer 21

data

Question 22

What is the term for the science that includes the collection, organization, and interpretation of numerical data?

Answer 22

statistics

Question 23

What are the procedures for submitting costs for medical services so that payment can be collected or denial can be determined?

Answer 23

claims process

Question 24

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?

Answer 24

assignment of benefits

Question 25

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?

Answer 25

explanation of benefits (EOB)

Question 26

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?

Answer 26

copays