CEHRS Clinical Operations Terms/Abbreviations

These flashcards cover key clinical operations terms and their meanings relevant for the CEHRS exam.

The abbreviation CDSS stands for __________.

Clinical Decision Support System (Statistical review)

__________ are predesigned forms for capturing data.

Clinical Templates/Data Capture

Interoperability refers to __________ between systems.

Meaningful Use/Communication and Sharing info between different systems

CPOE stands for __________.

Computerized Provider Order Entry

PHI is an abbreviation for __________.

Protected Health Information

The HIPAA Privacy Rule is related to the __________ concept.

Minimum Necessary

To ensure confidentiality, the HIPAA Security Rule mandates __________.

Required measures (contract)

Risk analysis involves looking at the __________ for possible issues.

system/process

Risk management focuses on identifying issues and taking steps to __________ them from happening.

prevent

Physical safeguards include limited access to __________.

work areas

To protect data, technical safeguards might involve __________.

Password Protection, Encryption

Administrative safeguards include __________ and staff education.

training

An Admission Note must be entered within __________ hours.

24

CC stands for __________ in the context of patient visits.

Chief Complaint (reason for visit)

Subjective elements come from the patient’s __________.

quotes

__________ data is observed or measurable, such as vital signs.

Objective

ROS stands for __________.

Review of Systems

Cloning in medical documentation raises concerns due to the potential for __________.

errors

ICD-10-CM stands for __________.

International Classification of Diseases 10th revision clinical modification

CPT is the abbreviation for __________.

Current Procedural Terminology

The revenue cycle includes tasks like start a claim, submit, manage, collections and __________.

F/U

Historical data includes the __________, reasons for encounter, and s/s.

Chief Complaint

PQRST-M is a method used in the __________ of present illness.

History

The social history might include marital status, occupation, and __________ use.

tobacco

Point of care (POC) data is entered during the __________.

encounter (e.g., Blood glucose)

Syndromic surveillance is utilized to identify __________ in public health trends.

trends

Human Factors Engineering adjusts systems to account for __________.

human issues (strengths, weakness, errors)

PCOs refers to __________ in the context of patient care.

Patient Care Orders (Nursing Orders)

Formulary alerts notify providers when insurance does not cover certain __________.

medicines.

Patient education resources should be __________ based.

Evidence