Professional Documentation Final Flashcards
Electronic Health Record for an Individual patient that is located within a single healthcare organization
EMR
Documentation of each patient encounter is included in
Family and personal history
When are editing and proofreading completed?
After you complete your first draft.
Effective writing includes:
All the Above
Using active voice
being polite and courteous
proofreading
An EHR facesheet template stores require patient information including:
demographic information
Goal for implementing EHR and ensuring compliance through meaningful use includes all of the following except:
Eliminate notice of privacy practice
HIPAA
Health Insurance Portability and Accountability Act
A correction in an electronic health record is called an
addendum
meaningful use compliance, which supports the Affordable Care Act, will eventually results in:
better clinical outcomes
Meaningful use is using the electronic health record to:
All the above
engage patient and family
improve care coordination
maintain privacy and security
Recording of patient vital signs is considered
clinical
One way to reassure patient of the security and confidentiality of their electronic health record
Allow them to view their electronic health record
Patients will form a quick impression of the provider’s office based on:
Appearance of professional documents
Professional documents and electronic health records serve as a legal record and must be prepared with
care and attention to detail
Professional medical correspondence should be:
Clear and concise
Proofreading includes all of the following except:
annotating
Disadvantages of electronic health records include
red and yellow only
system and software upgrade
staff training
Some examples of proper nouns are:
All the above
names of organizations
copyrighted tradenames
days of the week
Known as “HIPAA on steroids” because of its increase privacy regulations in 2009
HITECH
When preparing medical Documentation, it is okay to include slang and figurative language
False
Which of the following word is misspelled
Abcess
Which of the following word is misspelled
Menstration
