With SOAP, this is the information that the patient gives to the care provider
What is subjective information
100
This is the amount due from the patient at the time of visit
What is a co-payment
100
One way of importing hard copies of documents into the EHR system
What is scanning
100
This happens when you release information without a required authorization
What is a breach of confidentiality
100
This is a list of all providers and the patients they see
What is provider index
200
With SOAP notes, this is the information the care provider gathers from a physical exam or measurable test results
What is objective findings
200
This shows the amount charged for each procedure done in an office
What is a fee schedule
200
This is a message that appears on a screen in written form or as an icon to serve as a reminder to staff and care providers
What is flags
200
When might records be marked as sensitive or restricted access
When the material has to be held to a higher level of confidentiality (such as the case with a person related to office members, STD cases or when people are well known in the community)
200
This type of report includes totals rather than data for individual patients
What is summary (aggregate) report
300
When a patient is admitted to a hospital, the care provider documents the subjective and objective findings, along with the results of the physical exam in what report
What is the History and Physical Report (H&P)
300
This is a document that is often used in medical offices to capture the diagnoses and services performed
What is an encounter form (superbill)
300
this is a secure environment or private internal network that is available only to a select group
What is intranet
300
This is a written document that details what to do in the event of a disaster that affects the computer systems within a facility
What is a disaster recovery plan
300
This organization administers the meaningful use requirements of the HITECH Act
What is CMS (Center for Medicare and Medicaid Services)
400
When an electronic health record is used and the responses are chosen from a preformatted field, such as from drop-down menus, the data is called
What is structured data
400
These plans promote quality, cost-effective healthcare through monitoring of patients, preventative care, and performance measures of providers
What is managed care plans
400
Explain why customization is a beneficial feature in EHR software
Because everyone has their own preference on how they like their screen to look
400
This is a listing of all disclosures of a person's health information
What is a accounting of disclosures
400
This is diagnostic and treatment protocols that are based on proven research and documented best practices
What is evidence-based medicine
500
Besides the prescription itself, what other information can be sent to a pharmacy using ePrescribing
-Demographic information
-Insurance information
-Allergies
-Medication history
-Can be alerted to drug interactions
500
This is the fact that there is a medical reason to perform a procedure or service. Documentation exists in the patient record to show that there is sufficient signs, symptoms, or history to warrant the services provided
What is medical necessity
500
these are datasets that provide structure and are the building blocks for parts of the chart notes within EHR
What is master files
500
What does a Notice of Privacy Practices inform the patients of
-How their health information will be used
-Reasons why it may be released
-That they have the right to view and make copies
-May request amendments or file a complaint
500
If a patient and a doctor used audiovisual equipment to discuss the patient's health status, what are they engaging in