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Medical Records - paper and electronic Flashcards | StudBud
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Medical Records - paper and electronic
Medical Records - paper and electronic
20 terms
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StudBud Administration
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Review of terms and concepts for medical records
Flashcards
20 cards
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Practice quiz
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Questions
20
Answers
1
All of the following can sign a release for medical records, EXCEPT
spouse
parents of minor children
power of attorney-healthcare
legal guardian
2
Which item below would not be included in a hospital discharge summary?
hospital treatment
complications of treatment
follow-up care
patient demographics
3
Act that provided financial incentives to use EHRs to improve quality, safety & effectiveness
ONC
CCHIT
ACA
HITECH
4
Health information that the patient stores electronically on a computer or internet site
EMR
PHI
protected medical record
PHR
5
The main difference between an EHR versus an EMR.
interoperability
EMRs allow patient access
one is a paper chart
EHRs allow patient access
6
EHRs have this, so that it can be utilized by members in more than 1 healthcare organization
customization
specialty templates
interoperability standards
meaningful use
7
Which item below maintains each user's ability to work in certain areas of a patient's EHR?
Confidential code
Codeword
Password
Access code
8
A digital version of a patient chart kept in a single facility office
EHR
PPO
POMR
EMR
9
Term used to describe a patient who is not following the provider's medical advice.
AMA
Noncompliant
Stubborn
Anxious
10
This office is responsible for ensuring/enforcing the privacy regulations of medical records
Office for Civil Rights
HITECH
HIPAA
CDC
11
The patient's current medical problem with details of the problem listed
review of systems
progress note
physical exam
chief complaint
12
The term used when you make a correction in an electronic health record.
addendum
omission
correction
error
13
This format of medical record documentation breaks things down into smaller components.
POMR
CHEDDAR
POMR
SOAP
14
With this medical record system, it is easier to keep track of the patients progress
POMR
SOAP
TOMR
SOMR
15
Patient records serve dual roles, both as a communication tool and also as
a legal document
a patient portal
a HIPAA document
a billing document
16
Document that provides essential information about a test or procedure that is ordered
turnaround form
demographic requisition
medical history form
lab requisition
17
This is a picture of a tool that helps to evaluate a patient's progress over time?
spreadsheet
flow sheet
lab test results
graph
18
Type of audit completed after billing is submitted.
retrospective
prospective
internal
external
19
Which feature of an EHR program would be most helpful to review the practice's financial health
billing/coding
report generator
tickler file
electronic scheduler
20
Patients should receive this as it states how their private medical information will be handled
Notice of Privacy Practices
Privacy form
Notice of disclosure
Advanced Beneficiary Notice (ABN)