Med Assist Ch 8 Cards

21st Century Cures Act

federal legislation passed in 2016 designed to give patients greater control of specific personal health information in an electronic health record

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

the arrangement of items following one right after the other in the order in which they occur

clearinghouses

companies that receive, review, send, and manage insurance claims for physicians

covered entity

anyone required to follow HIPAA’s requirements. Health care providers, insurance companies, and insurance clearinghouses are included

cross-reference

notation in a file telling that a record is stored elsewhere and giving the reference; verification to another source; checking the tabular list against the alphabetic list in ICD-10 coding

demographic data

information gathered from individuals relating to age, gender, employment, place of residence, or other personal information

EHR Incentive Programs

a program established by the Centers for Medicare and Medicaid Services to provide incentive payments to eligible providers who show they are using electronic health records in a meaningful way

electronic health records (EHRs)

information about patients that is recorded and stored on a computer

flow sheet

color-coded sheets that allow informatino to be recorded in graphic or tabular form for easy retrieval; form that gathers all the important data regarding a patient’s condition and stays in the patient’s chart as a reminder of care and a record of whether care expectations have been met

Health Information Technology for Economic and Clinical Health (HITECH) Act

law enacted as a part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology

medical history

a patient’s past and present health status

medical history forms

records containing information about a patient’s past and present health status

microfiche

sheets of microfilm

microfilm

photographs of records in a reduced size

narrative

a paragraph indicating the contact with the patient, what was done for the patient, and the outcome of any action

numeric filing

arranging files by a numbered order

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

protected health information (PHI)

individually identifiable personal health information as defined by HIPAA. information that can be linked to a particular individual by name, code, or number is PHI

reverse chronological order

items placed with oldest first

SOAP

a style of charting that includes subjective, objective, assessment, and planning notes

source-oriented medical record (SOMR)

a method of organizing patient data into sections that correspond with the data source

subject filing

arranging files according to their title, grouping similar subjects together

workers’ compensation

employer insurance for treatment of an employee’s injury or illness related to the job