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10. E/M Codes
A physician can use e-prescribing software to electronically write a prescription for a patient.
A Continuity of Care Document (CCD) can be created by an HIS using HL7 formatting to provide an easily transferred snapshot of a patient's record.
A continuity of care record (CCR) is a collection of CCDs, spanning multiple patient visits, sometimes called patient encounters. Many CCDs can make up a CCR.
Current Procedural Terminology describes the procedure or treatments offered by healthcare providers.
Systemized Nomenclature of Medicine is a medical terminology standard used internationally to create consistency in keywords in medical documentation. SNOMED technology translates several ways to describe the same medical term into a single code.
National Drug Code Identifier is a code assigned to each drug used by the FDA to maintain a list of drugs being produced.
Picture archiving and communication system (PACS) centralizes all the different types of medical images into one information system, stores and retrieves medical images, and communicates medical images with other information systems.
Evaluation and management (E/M) codes are a subcategory of CPT codes that describe the level of care provided to a patient.
1. Portable x-ray machine
3. Vitals cuff
9. Vascular/Nuclear Stress Test
10. Glucose Monitor
Portable x-ray machine
A mobile X-ray machine that is small enough to be rolled to a patient's room or taken to a patient's house.
Magnetic Resonance Imaging (MRI)—Imaging that uses strong magnetic fields and radio signals to create an image of a patient's body. A patient lies down in an MRI machine and must remain still for extended periods of time in a noisy, cramped space.
An electroencephalogram (EEG) measures the frequency of brain waves. During an EEG test, sensors are attached to a patient's head to measure the electrical activity.
An imaging process that uses sound waves to create a picture of soft tissues inside the body.
A positron emission tomography (PET) is imaging that creates an image of the body or function of an organ. A radioactive tracer is introduced to the patient's body, usually injected into the patient's bloodstream.
A computed tomography (CT) is imaging that uses x-rays along with computing algorithms. A patient lies down in a CT machine while the CT machine rotates around the patient.
Vascular/Nuclear Stress Test
A physical test using an EKG that determines the capability of veins to return blood from the lower limbs to the heart.
Patient tracking software
Radio frequency identification (RFID)—A technology that uses radio frequency to track or locate a transponder, or tag.
Software used to schedule services offered that might include features that can reserve rooms, procedures, and personnel based on the type of procedure or service.
Order entry software
Order entry (OE) software facilitates the creation, duplication, and safety of orders given by healthcare providers.
Practice management software
Software used in small- to medium-sized medical offices for both clinical and business needs.
Billing & coding software
Software that receives data from a patient's EHR/EMR, converts the data into billable items, and submits the bill to the insurance company for
Tracking & auditing software
Every patient has the right by law to request to see who has accessed their health records. All software that contains e-PHI must have a tracking or auditing system to report who has viewed a patient's information.
A doctor who has an ongoing relationship with a patient and provides primary care for that patient.
Stat, derived from the Latin word statim, which means immediately. It is often used in the medical environment to expedite something.
The level of severity of an affliction.
Level 1, Severely unstable, seen by a physician immediately, usually requires an intervention.
Level 2, Potentially unstable, seen by a physician within 10 minutes, usually requires testing and medication.
Level 3, Stable, yet urgent, seen by a physician within 30 minutes, usually requires testing and medication.
Level 4, Stable and nonurgent, seen by physician when available, requires minimal testing and medication.
Level 5, Stable and nonurgent, seen by physician when available, requires no testing or procedure.
Hospital HICS Codes
1. Blue: cardiac arrest
2. Red: fire
3. Yellow: Disaster
4. Silver: hostage
5. Pink: child abduction
6. Gray: sever weather watch
7. Black: sever weather warning
8. Brown: bomb threat
9. Orange: activation of radiation
10. White: security
11. Purple: hazardous materials released
12. Lake: security lockdown
Trauma level 1
The trauma center is ready for the highest level of surgical care to trauma patients by providing equipment and a full range of specialists, including a certain number of surgeons, emergency physicians, and anesthesiologists at all times inside the hospital and not just on call from home. The hospital is also required to have a residency program for training physicians.
Trauma level 2
The trauma center provides comprehensive trauma care and collaborates with a Level I center.
Trauma level 3
The trauma center provides emergency resuscitation, surgery, and intensive care to most trauma patients. Other patients are transferred to a Level I or Level II trauma center.
Trauma level 4
The trauma center provides initial evaluation, stabilization, and diagnostic services. Patients are transferred to a higher level of care facility when
Trauma level 5
The trauma center provides initial evaluation, stabilization, and diagnostic services. Patients are transferred to a higher level of care facility when needed. If not open all hours, the trauma center must have an after-hours response protocol.
Controlled substance Level 1
High potential for abuse. No accepted medical use in treatment. No accepted safety standards for use under medical treatment. (heroin, LSD, ecstasy).
Controlled substance Level 2
High potential for abuse. May lead to severe psychological or physical dependence. (Morphine, opium, oxycodone, fentanyl)
Controlled substance Level 3
Potential for abuse is less than substances in schedules I and II. May lead to moderate or low physical dependence. May lead to high psychological dependence. (Less than 90 milligrams of codeine per dosage, buprenorphine products, and anabolic steroids)
Controlled substance Level 4
Low potential for abuse relative to substances in schedule III. (Propoxyphene and diazepam)
Controlled substance Level 5
Low potential for abuse relative to substances in schedule IV. Primarily small amounts of narcotics used for antitussive, antidiarrheal, and analgesic purposes. (Cough preparations containing less than 200 milligrams of codeine per 100 milliliters or grams)
SCH—schedule activity or appointments
Common inpatient departments
Common inpatient departments include OB/GYN, oncology, pediatrics, labor and delivery/NICU, ICU, transitional care unit, medical/surgical nursing unit, behavior health, post anesthesia care unit, operating room, and the Emergency Department.
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