Chapter 1
Early medical documentation of present day posttraumatic stress syndrome was first seen in:
the U.S. Civil War.
Chief Complaint is ...
Main reason for the visit
What is the first step in checking in a patient?
Verify the patient's identify
__________________ describes the measures that should be taken to prevent improper use of disclosure of PHI.
The Safety Rule
An EHR specialist is asked to generate a report that lists the financial status of all patient accounts. Which of the following reports should the EHR specialist create?
Billing payment status report
With the implementation of an EHR, it is helpful if employees can be ___________ so that they are able to perform more than one duty within the EHR.
cross-trained
What would the record of a patient who has not been seen by the provider in 3 or more years be considered?
Inactive record
Implementation of user names, passwords, and screen savers are examples of ______________.
safeguards
Giving two or more patients the same appointment slot with the same provider is known as:
double-booking
Genetic disease risk would be covered under which part of history?
Family
The fixed amount of money a patient is contracted to pay out of pocket at each visit is called:
the copayment
When entering the clinical care module, the ______________ will be displayed.
Patient dashboard
The office manager reviews the staff ____________ every 6 months to determine if any unauthorized information was accessed.
audit trail
A device that encodes documents in order to transmit them over telephone lines is a/an:
fax machine.
Documentation for an immunization would include:
The ___________ is a statement for the daily business transactions. It includes the list of checks and balances for the office for a specific date of service.
day sheet
The amount of time patients records must by law be maintained by medical office
When entering a patient's new insurance information, which of the following must be entered into the EHR to verify eligibility?
Policy holder
Purging is:
the practice of removing inactive and closed health records away from active records.
A report from insurance carriers to a service provider that describes payments and how the amount was determined is:
Remittance Advice
Practice management software:
May be included as part of an interoperable EHR and includes administrative functions like appointment books and billing
______________ is the term that describes the amount of time records must be kept in storage by a medical office
Retention period
Encryption and decryption technology are examples of:
technical safeguards
An EHR specialist is conducting an internal audit of encounter documentation for clinic registrations. Which of the following is a required document that approved disclosures of protected health information for unrelated treatment purposes under the HIPPA Privacy Rule?
Authorization
A coding classification system used to report professional services and procedures provided to a patient at ambulatory care centers, medical clinics, and other outpatient care facilities is _______________________.
Current Procedural Terminology, 4th edition (CPT-4)