41 terms

Chapter 8, Admin 2


Terms in this set (...)

HIPAA officer
Who coordinates and oversees the various aspects of HIPAA compliance in a medical office?
Original signature
A release of records request must contain the patient's:
First and last name associated with a diagnosis
Which is an example of protected health information?
Provider or insurer
If patients believe their rights have been denied or their health information isn't being protected, they can file a complaint with the:
Record is subpoenaed by the court of law
The only time the original record should be released is when the:
Do medical records have the same content if they are on paper or a computer disk?
Progress notes
Documentation of each patient encounter is called:
Electronic health records
Improved medication management is a feature of:
Design a written confidentiality policy for employees to sign
To maintain security, a facility should:
Reverse chronological order
Under source-oriented records, the most recent documents are placed on top of previous sheets, which is called:
The acronym "SOAP" stands for:
Problem-oriented medical record
The acronym "POMR" stands for:
Review of systems
Which of the following is contained in a POMR data-base?
Which of the following will reflect each encounter with the patient chronologically, whether by phone, by email, or in person?
Taping the paper across the top to a regular size sheet
Shingling is:
2 years
How long are workers compensation cases kept open after the last date of treatment for any follow up care that may be required?
Master patient index
A cross-reference in numeric filing is called a(n):
Security experts advise storing backup disks:
Filing cabinet
Drawer files are a type of:
The legal time limit set for filing suit against an alleged wrongdoer
Th statue of limitations is:
Alphabetic filing
Arranging of names or titles according to the sequence of letters in the alphabet
Chief complaint
Main reason for the visit to the medical office
Chronological order
Items placed with oldest first
Entity that takes claims and other electronic data from providers, verifies the information, and forwards the proper forms to the payors for physician
Covered entity
Health plan; health care clearinghouse; or health care provider who transmits any health information in electronic form in connection with a transaction covered under HIPAA
Notation in filing indicating that a record is stored elsewhere and giving the reference; verification to another source; checking the tabular list against the alphabetic list in ICD-9 coding
Demographic data
Information relating to the statistical characteristics of populations
Electronic health records (EHR)
Information about patients that is recorded and stored on computer
Flow sheet
Color-coded sheets that allow information to be recorded in graphic or tabular form for easy retrieval
Medical history forms
Record containing information about a patient's past and present health status
Sheets of microfilm
Photographs of records in a reduced size
A paragraph indicating the contact with the patient, what was done for the patient, the outcome of any action
Numeric filing
Arranging files by a numbered order
Protected health information (PHI)
Any information that can be linked to a specific person
Present illness
A specific account of the chief complaint, including time frames and characteristics
Problem-oriented medical record (POMR)
A common method of compiling information that lists each problem of the patient, usually at the beginning of the folder, and references each problem with a number throughout the folder
Reverse chronological order
Placing in order of time; usually the most recent is place foremost
A style of charting that includes subjective, objective, assessment, and planning notes
Subject filing
Arranging files according to their title, grouping similar subjects together
Worker's compensation
Employer insurance for treatment of an employee's injury or illness related to the job