Terms and Definitions Flashcards
Advanced booking
Scheduling appointments for patients on a future date.
CEU
Continuing education unit
Cluster scheduling
Grouping appointments for patients with similar problems or procedures.
CMS
Centers for Medicare and Medicaid Services
Coding
The use of numbers and letters to describe illnesses, disease, and medical procedures.
Conditioning
The removal of metal items from paperwork to prepare for placing medical records.
Controlled substances
Medications or substances listed by schedule and controlled under the Controlled Substance Act according to the potential for addiction or medical use.
Database
The area of POMR charting that includes information such as the patient’s chief complaint.
DEA
Drug Enforcement Agency. A federal law enforcement agency tasked with regulation of controlled-substances.
Durable supplies
Supplies that are expensive and not often replaced.
Federal Register
The official daily publications for rules, proposed rules, and notices of federal agencies and organizations.
Filing
Method by which medical records are kept to ensure ease in updating and finding of records.
Global periods
Includes all services related to a procedure during a period of time depending on payor guidelines.
Indexing
Order in which paperwork is added to medical record.
Informed consent
A form of patient consent in which the patient has been told and understands the procedure that has been prescribed.
Inpatient
Someone who has been admitted to a hospital or other health care facility.
Advanced booking
Scheduling appointments for patients on a future date.
CEU
Continuing education unit
Cluster scheduling
Grouping appointments for patients with similar problems or procedures.
CMS
Centers for Medicare and Medicaid Services
Coding
The use of numbers and letters to describe illnesses, disease, and medical procedures.
Conditioning
The removal of metal items from paperwork to prepare for placing medical records.
Controlled substances
Medications or substances listed by schedule and controlled under the Controlled Substance Act according to the potential for addiction or medical use.
Database
The area of POMR charting that includes information such as the patient’s chief complaint.
DEA
Drug Enforcement Agency. A federal law enforcement agency tasked with regulation of controlled-substances.
Durable supplies
Supplies that are expensive and not often replaced.
Federal Register
The official daily publications for rules, proposed rules, and notices of federal agencies and organizations.
Filing
Method by which medical records are kept to ensure ease in updating and finding of records.
Global periods
Includes all services related to a procedure during a period of time depending on payor guidelines.
Indexing
Order in which paperwork is added to medical record.
Informed consent
A form of patient consent in which the patient has been told and understands the procedure that has been prescribed.
Inpatient
Someone who has been admitted to a hospital or other health care facility.
Medicare
Government-based health insurance for people over the age of 65 and others with certain disabilities.
Non-durable supplies
Supplies that are inexpensive, and often used and replaced.
Objective
In the SOAP format, the clinical assessment of a patient. Test results and information that can be observed by others.
Open office scheduling
A method of allowing patients to access medical care without making an appointment.
Outpatient
Patient who has received a procedure, treatment or test that does not require an overnight stay.
Pathology
The branch of medicine that treats the essential nature of disease as changes in structure and function.
POMR
Problem Oriented Medical Records that divide records into four sections - the database, problem, treatment, and progress.
Privacy Rule
A national standard to protect a patient’s medical record and health information.
Radiology
Medical specialty that uses imaging to diagnose and treat disease.
Releasing
The marking of a document to indicate that the records is ready for filing.
Security Rule
A national standard that requires health care professionals to take specific technical precautions to ensure that patient information stored of transmitted in an electronic format remains confidential, accessible, and of a high quality,
SOAP
Charting format that uses subjective, objective, assessment, and planning to organize the information.
Sorting
Method of preparing medical records for filing by putting into order.
Subjective
In the SOAP format, any information stated or perceived by the patient; will include patient’s chief complaint.
Tabular List
Volume 1 of the ICD-9-CM containing disease information.
Wave scheduling
A method of scheduling patients in which multiple patients are scheduled at one same time and seen in the order they arrive at the office.
