MIBC - Introduction to Electronic Health Records

Organization which works to provide unbiased, authoritative advice to decision makers

An examination of the patient's body for signs of disease

A secure environment or private internal network that is available only to a select group

What must be done before any administrative or clinical data is entered for a patient?

Uses a single database to share health information with other healthcare providers or entities.

Federal entity charged with coordination, implementation of HIT and electronic exchange of info

Computerized system for enhancing viewing and sharing of images

Entering physician orders electronically, transmitted directly to appropriate department

Comprehensive record of all health documentation for a patient, can be shared electronically

ICD-10-CM was effective on 1 October of what year?

What year was ARRA signed into law by President Obama?

An explanation of charges for services

What Does ADT stand for?

A unique number assigned to each patient seen by a facility

A document that is used in medical offices to capture the diagnoses & procedures performed:

Software the recognizes the words being said by the person dictating, converts speech to text:

Economic "stimulus plan" which included provisions for the HITECH Act

EMR is what for EHR?

ePrescribing software is a component of what requirements of HITECH?

Software used to gather data on every patient and perform administrative functions:

When do charges start accruing?

Who is ultimately responsible for the information entered into the EHR

Patient's description of current complaints, such as when the symptoms started

Report of all people within a facility who have had access to a patient's protected health info

Comparison of one set of stats to the overall stats when the same variable is used for each

Monies coming into a medical practice

Intentional deception, in which healthcare takes advantage of a patient

How long should MPI be kept?

Required by HIPAA, releasing minimum information to satisfy the reason information is needed

The process of contacting the insurance carrier & receiving validation of coverage

Additional functions that allow for greater use of EHR functionality

Software that has a special purpose

A visual comparison of actual performance to required performance

What does SOAP stand for?

A permanent listing of all patients who have received care in a hospital:

Ordering of tests & procedures that occur at the same time that the patient is being seen:

Typically, questions on a form are not duplicated, with the exception of what?

Coding system required by Medicare/ Medicaid to document services, equipment, transport

Co-pay does not exist for whom?

Ability of one computer system to accept/ send data to another system without loss of integrity

Legal patient record that is created within any healthcare facility:

When does the patient's account for each visit begin?

Organization that assists healthcare providers with selections/implementations of EHR systems

Accountable Care Organizations base payments on what?

How often should patient information be verified?

A set of standards that makes sharing of data between or among healthcare entities possible

Monies being paid from the medical practice

Unique identifier used on insurance claims to identify the care provider

What is the release of information to an outside source called

Software that recognizes the words being said by person dictating, and converts speech to text

Part of HITECH requirements, increases EHR use in a meaningful way through monetary incentives:

The out-of-pocket payment amount a policy-holder must meet before insurance covers the services

What type of data cannot be tracked?

A report, completed by a care provider, which summarizes a patient's stay in the hospital

Software that recognizes the words being said by the person dictating & converts speech to text

A detailed accounting of claims for which payment is being made by an insurance company

What is HEENT?

The primary person covered by an insurance plan

Whom do physicians contract with to provide care at predetermined rates?

Coding and billing that is inconsistent with typical coding and billing practices

A listing that is filed in chronological order based on when something occurred

Releasing information without a required, properly executed authorization

Form used to submit insurance claims for hospital patients

What year was HIPAA passed?

Electronically transmitting prescriptions from care provider to pharmacy

An agency whose purpose is to certify EHR for functionality, interoperability, and security:

The amount charged for services rendered in a physician's office by CPT code

Of the 2011 menu objectives for Medicare, how many of the 10 must be met?

Measurements taken to determine the status of basic body system functions

Forms used in physicians' offices to submit insurance claims

Set of standards, services, and policies that enable the secure exchange of health information

Classification system used to convert narrative diagnoses and procedures into numeric codes:

What year was the ACA signed into law?

The coding system used to convert narrative procedures and services into numeric code:

Document exchange standard used to share patient summary info, such as a patient being referred

Maintaining the accuracy and integrity of data

What does a clearinghouse do?

Permanent record of access, additions, deletions, amendments of health records

Right to expect one's personal space to be respected while undergoing healthcare

Basic functions , collection of data, that should be completed on a patient's visit