Organizations/ Agencies
An organization that develops standards for health data interoperability between clinical and administrative systems
What is HL7?
Monitors health events, that can be used to help public health officials with an early warning system.
What is syndromic surveillance?
Individually identifiable health information stored or transmitted by covered entities or business associates
What is PHI (protected health information)?
Covers prescription drugs
What is Medicare Part D?
Different sections of the SOAP note
What is subjective, objective, assessment, and plan?
Federal agency that oversees HHS programs like MCR and MCD to prevent fraud, waste and abuse
What is the OIG (Office of Inspector General)?
Assists clinicians at the point of care to help analyze and reach a diagnosis based on the patient data.
What is CDSS? (Clinical Decision Support System)
three safeguards that help ensure the security of ePHI?
What are administrative, technical and physical safeguards?
Covers medically necessary services or supplies (ambulance, DME, preventatives)
What is Medicare part B?
Includes current Dx, both subjective and objective data. Documents the impression and interpretation based on the information obtained
What is the assessment?
Provides health coverage through MCR, MCD, CHIP and marketplace. The agency is to improve quality and equity outcomes in the healthcare system
What is CMS?
System for identifying medical laboratory observations
What is LOINC (Logical Observation Identifiers Names and Codes)?
Passwords, logout procedures, workstation and device security and facility access and control
What are physical safeguards?
Policy that helps cover OOP costs associated with original Medicare such as copayments or coinsurance and deductible
What is Medigap?
Includes how the patient is feeling, changes in symptoms, new symptoms and pain scale
What is subjective?
Organization committed to advancing safety, quality as well as transforming healthcare.
What is the Joint Commission?
Medical Imaging system that provides storage and access to images from multiple modalities.
What is PACS (Picture Archiving and Communication Systems)?
Audit trail, automatic logoff, encryption, unique user ID, virus protection
What are technical safeguards?
Covers hospital, SNF (skilled nursing facility), hospital in patient, home health and hospice
What is Medicare Part A?
Includes observable symptoms, test results and diagnosis. Also includes vital signs, physical examination and current medications.
What is Objective?
Federal agency that ensures safe and healthy working conditions
What is OSHA?
Data base that stores information on radiology ordering, scheduling, appointments, referrals and reporting used to track patient data
What is Radiology Information System (RIS)?
Risk management and analysis, security management access, information access management.
What are administrative safeguards?
Known as Medicare part C it includes all parts of original Medicare, plus prescription coverage
What is a Medicare Advantage Plan?
Documentation to include constitutional symptoms I weight loss, fever) eyes, ears, nose throat, cardiovascular, respiratory, gastrointestinal, and genitourinary
What is the review of systems (ROS)?