1.1-1.5
2.1-2.8
3.1-3.10
4.1-4.4
Enter Category
100
listing of all patients seen in an office or hospital
What is Master Patient Index (MPI)
100
A dictated report, a written progress note, voice files, or scanned images of original documents.
What is Unstructured data
100
The form used to submit insurance claims for hospital patients.
What is UB-04
100
Previous medical conditions for which the patient has been treated
What is Past Medical History
100
An acronym for the documentation used in a care providers office to record the patients symptoms signs assessment and plan of care; subjective, objective, assessment, plan
What is SOAP
200
S.O.A.P
What is: Subjective Objective Assessment Plan
200
A record kept by the patient, that contains a persons health history, immunization status, current and past medications, allergies and instructions given by a care provider; it often includes patient education materials as well **DAILY DOUBLE**
What is a Personal Health Record (PHR)
200
The form used by physicians offices to submit insurance claims.
What is CMS-1500
200
A system-by-body system inventory of any symptoms the patient is having or has had based on a series of questions asked by the care provider
What is Review of Systems
200
A report completed by a care provider which summarizes a patients stay in the hospital. It generally includes final diagnoses a summary of the patients course in the hospital an procedures performed recap of diagnostic results and discharge instructions.
What is Discharge Summary
300
Through a single database many different functions can take place and information can be shared
What is interoperability
300
Computerized system for enhanced viewing and sharing images such as x-rays, scans, ultrasounds, and mammograms
What is Picture Archiving Communication Systems (PACS)
300
A set of standards that makes sharing of data between or among health-care entities possible.
What is Health Level Seven (HL7)
300
Documentation of diseases and conditions in immediate family members. (e.g., diabetes, cancer, or heart disease)
What is Past Family History
300
Electronically transmitting prescriptions from care provider to pharmacy
What is ePrescribing
400
Software that recognizes the words being said by the person dictating and converts them to text
What is Speech(voice) Recognition
400
Part of the requirements of the health Information Technology for economic and Clinical Health Act which is meant to increase the use of an electronic health record through monetary incentives provided the EHR is used in a meaningful way to improve patient care
What is Meaningful Use
400
A document exchange standard used to share patient summary information such as in the case of a patient being referred from one healthcare provider to another
What is Continuity of Care Documents (CCD)
400
Measurements taken to determine the status of basic body functions
What are Vital Signs
400
The ability of one computer system or component to accept or send data to another system without loss integrity or meaning.
What is Interface
500
Documentation, dictation ordering of tests and procedures that occur while the patient is being seen
What is Point of care
500
An independent, non profit, nongovernmental organization that works to provide unbiased and authoritative advice to decision makers and the public.
What is Institute of Medicine
500
Based on HL7's approved clinical Documentation Architecture (CDA) this is a data standard used for reporting quality measure data and is EHR compatible across different health IT systems
What is Quality Reporting Document Architecture (QRDA)
500
Previous surgical procedures the patient has undergone the approximate dates name of surgeon reason for procedure and complications if any
What is Past Surgical History
500
A listing kept in the patients health record of all current (active) and resolved medical conditions
What is a Problem List
M
e
n
u