This signed document acknowledges that the patient knows the risk and benefits of their procedure
What is a consent form?
100
The date that new ICD-9 codes go into effect each year.
What is October 1st
100
Number of patient identifiers on each page
What is 2?
100
The legal term for the federal law that lays the groundwork for patient privacy and information security standards in health care
What is HIPAA?
100
Dangerous abbreviation for daily regarding medication dosing
What is q.d
200
If both H&P and Discharge Note have not been completed. This deficiency will be added for the physician to dictate.
What is a Short Stay Summary deficiency?
200
The coding and reimbursement system to code outpatient procedures.
What is CPT?
200
Name of at least 3 document types that are COLD-Fed?
What is Lab, Transcription, HEC, HED, HSM, Powerscribe
200
The unauthorized acquisition, access, use or disclosure of PHI which compromises the privacy or security of such informaiton, except where the unauthorized person to whom such information is disclosed would not reasonably have been able to retain such information?
What is a breach?
200
Patient type used for patient's registered in PLUS with a STAR demographic interface
What is TO_?
300
These admissions are for "procedural stats only" and do not require a H&P or Discharge note
What are T-VAX Outpatient Infusion Admissions
300
The year that ICD-10 will go into effect
What is 2013?
300
H&P's stay in the chart if they are within _ days of admission
What is 30?
300
The act of looking at your own or someone you know's protected health informtion without authorization via using SLHS applications/resources
What is inappropriate access to PHI or snooping?
300
Name of the transcription BSR (backend speech recognition) application
What is Turbo?
400
This comes after a physician has received a letter of incomplete and before suspension.
What is a final notice?
400
The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
What is principal diagnosis?
400
Name at least 1 Go-Live HPF date for a facility
What is 7-1-2001 for Plaza; 3-5-2002 for SLS; 9-1-2002 for SLN; 12-2007 for Cushing; 3-1-2002 for SLCI; 1-2006 for SLELS.
400
Document used to appropriately request and obtain copies of your own or someone you know's protected health information
What a patient authorization form
400
Abbreviation for a dictator with an accent
What is ESL (english as second language)
500
The document includes information such as RT Data, Medications, Gases, and Drips
What is a PICIS Anesthesia Record/Anesthesia Record ?
500
Reporting options for Present on Admission indicators
What is "Yes-Y", "No-N", "Unknown - U"; "Clinically Undetermined - W"; "Exempt - E".
500
Name of the most recent DCS version upgrade that occurred on 10/10/10
What is 13.5?
500
Individually identifiable data, in any medium, collected and directly used in and/or documenting healthcare or health care status?
What is the legal medical record?
500
Work types 21 and 29 were designed for which physician group?
What is SLCC - Saint Luke's Cardiovascular Consultants