CEHRS (GREEN)

_______ AUTOMATICALLY ASSIGNS THE APPROPRIATE DIAGNOSIS AND PROCEDURE CODES BASED ON CLINICAL DOCUMENTATION IN THE EHR

Computer-assisted coding

What are the only 2 situations when disclosure of PHI is mandatory?

1. patient or legally authorized person requests it

2. Part of an investigation by the department of health and human services

Family History

Major health problems in the patients family

Covered Entity

Any medical or health care service, organization, agency, or individual that has protected health information

Point of care

Clinical staff are able to document information in the patients chart as they provide care

Social history

1. Martial status and/or living arrangements

2. current employment

3. us of drugs, alcohol or Tabaco

4. level of education

5. Intimate history

Objective

Is anything anything that can be observed or measured by clinical staff like vitals, test end imaging results, and physical examination findings

_______ is the main reason for the unit as stated by the patient

Chief Complaint (CC)

Subjective

A summary of what the patient tells the clinical staff about their history, family history, problems, concerns, symptoms, and goals

Clinical Decision Support system (CDSS)

a program designed to prompt providers with clinical decisions

patient encounter begins

when the patient arrive at the office and is greeted by office staff

Workflow of the office

1. check in at front desk

2. Exam room with CMA and providers

3. Provide sample

4. Give sample to lab

5. Check out at front desk

Formulary alerts

CDSS notifies providers that a medication they prescribed is not covered by the patients insurance

A _______ is documentation that a provider copied from a prior visit.

Cloned Note

Plan of care

A referral to specialist, medication the doctor wants you to take future treatments or visits

What is the preexisting data from drop-down menus, default settings, templates, and check boxes to document individual patient information called?

Coded Data

Security Rule

Standards to prevent inappropriate access to transmission of PHI

Risk analysis and management

identifying where and how much data could be accessed inappropriately and taking steps to prevent it

Real-time data

Entering the patients encounter documentation into the EHR system before the end of the visit

______ are predesigned forms for capturing data specific to an organizations workflow and tasks

Clinical Templates

Concurrent Coding

This coding technique allows an EHR specialists to review clinical documentation while the patient is actively receiving treatment

Past History

Including: medication, allergies, previous health problem, surgeries, prior hospitalizations, immunizations and dietary status

What section of the EHR would a patient’s history of alcohol use be documented?

Social History

System drug utilization review program

Generates alerts for the provider on potential interactions between new prescription and the patients medication list, inappropriate dosage or potential reactions from known allergies.

Review of systems (ROS)

providers asking patients about symptoms related to specific body organ systems.

Practice management System (PMS)

manage revenue cycle processes

If a patient dies when receiving inpatient care. What is entered into the patients EHR for discharging disposition?

Expired

Physical Safeguards

Limiting access to work areas, proper disposal and re-use of electronic media and devices

Incidental Disclosure

Minor disclosures that may occur during legitimate use of information even when reasonable security measures are in place.

What can be customized for the practice and by who?

Templates and EHR vendor

Minimum Necessary Concept

Protecting patient health information by limiting access based on need

Under what events can a patient’s PHI be released without patient authorization?

Treatment, Payment, and health care operations

Protected Health Information (PHI)

Health information that is specific to a patient.

What information can identify an individual?

Name, age, sex, address, demographic information, account information, social status, clinical status

What is used for e-prescribing in an outpatient setting

Computerized provider order entry (CPOE)

In Patient Requirements

A patient is admitted to the hospital, stays more than 24 hrs., and is discharged from the hospital

How can patients get access to their records

Patient Portal

What kind of data is used when the provider is documenting in the notes section of the EHR?

Text data

Public Interest

Data on vaccines, communicable diseases, danger to the public, some law enforcement, and worker’s compensation activities

Privacy Rule

Circumstances in which PHI can or must be disclosed