Study sets, textbooks, questions
Upgrade to remove ads
Terms in this set (75)
documentation format that allows healthcare professionals to capture all aspects of a patient encounter
ability to access another provider's practice management software for patient care purposes
assistant who enters the dictation of a care provider into a patient record
voice recognition technology
software that automatically turns spoken words into text and learns voice inflections the more it is used
Computerized Physician Order Entry (CPOE)
electronic entry of care provider orders for direct transmission to appropriate departments
History of Present Illness (HPI)
patient's description of current symptoms
Point of care
immediate, real-time documentation of patient procedures
comprehensive record of a patient's complaints and conditions
EMR feature that is part of HITECH's meaningful use requirements
Speech recognition technology
software that recognizes spoken words and converts them into text
Which of the following statements would not be included in the history of present illness?
Blood pressure is 130/84, right arm, sitting
Which of the following would most likely require a complete review of systems?
Notes about a prescription ordered for a patient would appear in the ____ section of a SOAP note.
A ROS covers information likely documented in the:
medical history form
EHRclinic has the capability to ____ the status of an order.
The biggest advantage of speech recognition software over manual transcription is
speed of turn-around time
Information gathered during a provider's physical exam would appear in the ___ section of a SOAP note.
The more speech recognition software is used, the
more it learns voice inflections, what the dictator is saying, and becomes more accurate.
There must be a ____ to perform any tests or treatments.
care provider order
A person hired to manually record a physician's recorded spoken words into a typed report is known as a...
Which of the following elements of an HPI are collected at a visit?
only those that apply to the patient's chief complaint
The extent of a physical exam largely depends upon which of the following?
patient's chief complaint
Promoting Interoperability (Meaningful Use) regulations require the keeping of an up-to-date
The use of ePrescribing is part of the requirements for
This chapter discussed many advantages of the EHR functionality of ePrescribing. Look at the list below, and select any item that representsa benefit of utilizing ePrescribe capabilities.
Dosing errors are avoided thanks to pop-up alerts.
Patient wait time for medicine is reduced.
Handwriting and legibility issues are reduced
Prescription renewals are made more efficient.
Food and drug interactions with prescribed medication are flagged.
Quality of care is improved.
act of deception which takes advantage of another person or entity
actions, such as posting payments or processing claims, done in a practice management system to update patient accounts
form of insurance that monitors patients, care, and performance to ensure quality
managed care plan
monies coming into a medical practice.
codes representing the face-to-face time spent with a provider
evaluation and management codes
list of how much is charged per service by CPT code
the primary individual covered under an insurance plan
formal, written guidelines that describe how a healthcare office intends to follow established rules and regulations
portion of a bill that is usually the responsibility of the patient; typically collected upon check-in
form of cost sharing with an insurance carrier in which the patient pays a percentage of medical expenses.
document sent from an insurance company to a subscriber outlining payment decisions
explanation of benefits
using the diagnostic and procedure codes together to show medical necessity.
The information contained in the encounter form is eventually transferred to the ________ for submission.
Only services deemed medically ________ can be billed to insurance.
What does the "CM" stand for in ICD coding?
The amount of a patient's co-pay may vary by
Charges begin to accrue once the ______
medical assistant or care provider interacts with patient.
A remittance advice is typically given to a/an ________ , whereas an explanation of benefits is typically given to a/an ________ .
When submitting claims to insurance carriers, providers show medical necessity by
using code linkage
To avoid negative consequences, a compliance plan should be ____ in every hospital and medical office.
The ________ is usually the person to set up information libraries within practice management software programs.
Who is the only person authorized to make a diagnosis?
To check if a claim has been paid, which menu will the healthcare professional look at?
Which of the following is true of the Pioneer ACO model?
Providers share in a greater percentage of savings, but they also share in a greater percentage of financial losses.
Depending on the terms of a patient's insurance coverage, the balance remaining after insurance has paid may be
written off as paid in full or sent to collections.
Expected methods of payment are discussed when a patient
makes an appointment
a break or failure of security measures that results in information being compromised
breach of confidentiality
keeping information about a patient to oneself
devices such as laptops, PDAs, and desktop computers that are at risk for theft
permanent record of the changes made to various documents; available even after files are deleted
deviant program, stored on a computer floppy disk, hard drive, or CD, that can destroy or corrupt data
person or group who has legal right to access protected health information by virtue of being a healthcare provider, clearinghouse, or health insurance plan
private, secure code that allows a user access to computer systems and software
documentation for addressing critical issues in the event of a crisis
disaster recovery plan
listing of patient information, such as hospital room number
security measure in which words are scrambled and can only be read if the receiving computer has the code to read the message
In the event of a breach, who may be held responsible?
all of these
(providers, office staff, the facility)
Which of the following would be considered a covered entity?
Of the following, which factor contributes to the user rights allowed a user?
It is critical that backup files be stored
HITECH regulations require that ____ information releases are accounted for.
(external, internal, no)
According to HIPAA regulations, healthcare providers must use ________, as opposed to written documentation to store and transmit information to insurance carriers.
all of these
Promoting Interoperability standards require offices to select an EHR that is
Releasing information without proper authorization is called a/an
breach of confidentiality
When a document is amended or changed in an EHR, the original documentation is
An office's compliance manual should be kept in a/an ____ location.
The sharing of health information must be done in a ________ environment.
Under a care provider's order, medical assistants and nurses ________ allowed to send an ePrescription or call in a refill prescription to a pharmacy.
To help guard against security breaches, emails containing protected health information should be
The mission of HIMSS is to
lead healthcare transformation through the use of health information technology.
Sets found in the same folder
Ch 8 Heart
Ch 11 Lungs
Integrated Electronic Health Records Chapters 1 & 2
Sets with similar terms
Integrated Electronic health records (Key Terms) C…
MED 103 - Chapter 1 - test
Principles of Health Information Resources Chapter…
Other sets by this creator
Healthcare Delivery Final Exam
Ch 15 hw
Ch 14 hw
Ch 13 Hw
Other Quizlet sets
Domain 1: Cloud Concepts
General Psychology CH.10
Home Front Study Guide Part 1