Professional Documentation Final Review Flashcards
Define EHR:
Accessible by multiple organizations.
Define EMR:
Accessible by a single organization.
True or false? Family and personal history includes documentation of each patient encounter, phone calls, and refills.
True
When is editing and proofreading done in the writing
process:
After you complete your first draft.
How do you ensure effective writing:
Active voice, proofreading, being polite and
courteous.
A face sheet contains what type of information:
Demographic
Goals of meaningful use:
Improved health outcomes, increased efficiency,
and maintain security of PHI.
HIPAA stands for:
Health Insurance Portability and Accountability
Act.
How do you correct an electronic record:
With an addendum.
Adhering to meaningful use will result in:
Better clinical outcomes.
Purpose of meaningful use:
Engage patients and family, maintain privacy
and security, and improve care coordination.
Billing and coding is administrative and patient vital signs
is:
Clinical
Reassure patients of the confidentiality and security of
their electronic records by:
Allowing them to view their electronic record.
Patients form an opinion about the office based on:
The appearance of professional documents.
Care and attention to detail must be given to electronic
health records because they are:
Legal documents.
