1-FBLA
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84 Terms
"Health record"
"Written or graphic information documenting facts and events during patient care; may be paper or electronic"
"Electronic Health Record (EHR)"
"Centralized electronic collection of a patient’s past
"Electronic Medical Record (EMR)"
"Electronic medical record used by an individual physician for a patient"
"Difference between EHR and EMR"
"EHR contains data from multiple providers; EMR is limited to one provider"
"American Recovery and Reinvestment Act (ARRA) of 2009"
"Encouraged adoption of EHRs through financial incentives from 2011–2016"
"Common health record content"
"Includes demographic info
"Problem-Oriented Record (POR)"
"Organizes patient data by problem using flow sheets
"Source-Oriented Record (SOR)"
"Arranges documentation by source such as labs
"Advantages of EHR"
"Eliminates physical storage
"SNOMED-CT"
"Standardized medical terminology coding system used in EHRs"
"Medicare Modernization Act"
"Created Commission on Systemic Interoperability to improve healthcare data access"
"Electronic medical report"
"Permanent legal document summarizing examination or treatment outcomes"
"Insurance claim"
"Includes date of service
"Documenters"
"Healthcare professionals who record patient information chronologically"
"Documentation"
"Charting patient care electronically
"Speech recognition system"
"Computerized voice recognition used to generate medical documentation"
"Medical editor/correctionist"
"Proofreads and edits computer-generated medical documents"
"Attending physician"
"Physician legally responsible for patient care"
"Consulting physician"
"Physician whose opinion is requested for patient evaluation or management"
"Non-physician practitioner (NPP)"
"Healthcare provider such as NP or PA who treats patients under state law"
"Ordering physician"
"Physician who orders tests
"Primary care physician (PCP)"
"Physician who manages patient care and referrals"
"Referring physician"
"Physician who sends a patient to another provider for services"
"Resident physician"
"Physician in specialty training under supervision"
"Teaching physician"
"Physician responsible for supervising residents and students"
"Treating physician"
"Physician who provides care and uses diagnostic results for management"
"Reasons for legible documentation"
"Prevents payment denial
"Evaluation and Management (E/M)"
"Medical services involving patient evaluation and care planning"
"Centers for Medicare and Medicaid Services (CMS)"
"Federal agency administering Medicare and Medicaid"
"Medical necessity"
"Criterion insurers use to approve or deny payment for services"
"Advance Beneficiary Notice (ABN)"
"Notice informing Medicare patients of non-covered services"
"Audit"
"Review of records to detect fraud or improper billing"
"External audit point system"
"Scoring system to evaluate completeness of medical documentation"
"Consequences of miscoding"
"Refunds
"If it is not documented"
"It is considered not performed for reimbursement purposes"
"Prepayment audit"
"Audit conducted before insurance payment"
"Postpayment audit"
"Audit conducted after insurance payment"
"Billing red flags"
"Unusual patterns such as repeated codes or lack of documentation"
"Compliance program"
"Policies ensuring legal and ethical medical billing practices"
"Elements of compliance program"
"Standards
"Software edit checks"
"Automated screening of insurance claims for errors"
"Addendum"
"Late entry added to justify or correct documentation"
"Faxed medical records"
"Acceptable if permitted by law and properly secured"
"Protected Health Information (PHI)"
"Individually identifiable health information protected by HIPAA"
"Electronically Stored Information (ESI)"
"Health information stored in electronic systems"
"Metadata"
"Data describing authorship
"Subpoena"
"Legal order requiring appearance or production of records"
"Subpoena duces tecum"
"Order to produce specific documents"
"Record retention"
"Storage of health records per legal requirements"
"Federal False Claims Act"
"Law penalizing fraudulent insurance claims"
"HIPAA Notice of Privacy Practices"
"Document explaining patient privacy rights"
"Termination of physician-patient relationship"
"Formal written notice ending care responsibilities"
"Error correction (paper record)"
"Single-line strikeout with date and initials"
"Error correction (electronic record)"
"Addendum with timestamp and electronic signature"
"SOAP charting"
"Subjective
"CHEDDAR charting"
"Chief complaint
"Medical chart function"
"Documents care
"Paper chart"
"Physical binder organized with tabbed sections"
"Electronic chart"
"Computerized patient record accessible across departments"
"Flagging charts"
"System used to identify patient order status"
"Clip chart"
"Temporary daily-use chart for frequent documentation"
"Admitting data"
"Biographical
"Physician orders"
"Written
"Graphic charts"
"Flowsheets tracking vital signs and trends"
"Nursing notes"
"Documentation of patient care activities and observations"
"Laboratory data"
"Recorded lab test results and trends"
"Diagnostic procedures"
"Reports such as X-rays
"Operating room report"
"Narrative of surgical procedures performed"
"History and Physical (H&P)"
"Admission note detailing medical history and exam"
"Progress notes"
"Chronological updates on patient condition and treatment"
"Medication Administration Record (MAR)"
"Log of administered medications"
"Miscellaneous chart section"
"Includes ambulance reports and discharge orders"
"Who may access charts"
"Healthcare staff
"Patient Bill of Rights"
"Guarantees respectful care
"Expressed consent"
"Permission given verbally or in writing by competent patient"
"Implied consent"
"Assumed consent in emergency situations"
"Informed consent"
"Written agreement after full disclosure of risks"
"Explanation of Benefits (EOB)"
"Insurance document explaining covered services"
"Health Maintenance Organization (HMO)"
"Insurance plan requiring PCP referrals and in-network care"
"Preferred Provider Organization (PPO)"
"Insurance plan allowing out-of-network care at higher cost"
"Health Savings Account (HSA)"
"Tax-advantaged account for medical expenses"
"ICD-9"
"Outdated diagnostic coding system"
"Body systems"
"Includes skeletal
Note 
Flashcards (82)