Study Guide Flashcards
The progress note includes such
Details as the physical exam and the history of present illness
Moving to an electronic health record lessens the need for
Many office supplies used to house records, such as Folders and clips for each file
Because of the immediate availability of data about each patient, medication errors have
Decreased with the use of EHR
The 1st step of the information chain in electronic system is
Before any information can be documented, the patient must 1st make an appointment.
EHR clinic is a combined
Practice management EHR software
A patient’s age is not
Clinical information
Before making an appointment, the receptionist needs to know the condition or symptoms for which the patient is being seen before determining
The amount of time allotted for each appointment
The health information management and information technology departments are
Closely related
Registered health information administrator (RHIA) professionals have the education and background necessary to hold positions such as
Cancer registrar, privacy officer, software analyst, or compliance officer
Protected health information is any information, such as
Name, address, phone number, or medical information, that identifies the patient
Registration that takes place from the same department or area as known as
centralized or (central) registration
Regardless of the number of times the patient is seen, he/she is entered only
One time in the MPI
The name of the form should be related to its purpose, such as
“patient history” or” physical exam”
Commonly, the box in which electronic data is entered is known as
A field
A review of Systems is the
Collection of subjective symptoms related to a patient’s body systems
Blood pressure is an objective finding it would not be included in the
History of the present illness
A person hired to manually record a physician’s recorded spoken words is known as a
Transcriptionist
The review of systems will cover the information
Documented on a medical history form
One piece of an annual exam is a complete review of each body system. A review of systems is an
Inventory or subjective symptoms experienced by a patient for each body system
Only the sections of the history of present illness that apply to a patient’s chief complaint are
Collected At a visit
Knowingly billing for unnecessary or non occurring services constitutes
As fraud
The fee schedule is the document that includes
The fee charged for each service rendered in a medical practice
HCPCS level 2 codes are used to
Code supplies
The medical history is documented on the patient’s health record, but not on the
Superbill
It is the office of inspector general that is in charge with
Investigating cases of suspected fraud or abuse
It is through the ACA that reimbursement methodology has become tied to
Quality and coordination of care
It is possible to have too many flag alerts set up in the EHR clinic, so use
Caution to only create critical flags
A patient who often misses appointments, will have an alert set to appear on her record: this alert is known as
A flag
Providers must provide proof of citizenship during the
Credentialing process
Care providers typically agree to lower rates of reimbursement when contracting with
Insurance carriers
Custom reports have at least
2 variables
A narrowing detail such as “patients 30 years or older” is called
A filter
Any emails containing protected health information should be
Encrypted for security
HIPPA regulations require that EHR systems store and transmit information in the form of
Codes, rather than text based (written out) descriptions
An EHR must be certified to comply with
Promoting interoperability standards
Paper forms need to be logical for Ease of
Completion
A patient’s histories are gathered by
Asking the patient questions and/or having the patient or legal guardian complete a medical/surgical history form
Discrepancies and information are noted in
A details Box
It is critical to document any discrepancies in
Patient information
BMI stands for
Body mass index
The quality of a scanned (digital) image is known as
The resolution
It is a great idea to plan ahead and ensure that orders are completed in a
Timely manner, however ordering a desk calendar is low priority
Task lists allow a user to
Keep track of tasks needed to be completed
Flags give healthcare professionals
Reminders about individual patients that they would not otherwise remember
A default Value automatically appears within a
Field since that particular valve is common
A copay (copayment) is the
Fixed amount that is collected at the time Of a visit for most patients covered under managed care plans
The appointment is the 1st step in building the
Claim
