Documentation
This information within a patient's history may be a predictor of the patient's future health.
What is family history
All patients that register through the same department regardless of the type of patient is known as this type of registration.
What is centralized registration.
This is the reason for a patient's visit.
What is the chief complaint.
This is an acronym for the act which increased the privacy and security of electronic health information.
What is HIPAA
The name of the software we used this quarter
What is EHRGo
This is the process of converting a document from paper format to digital format.
What is scanning
Billing for unnecessary or non-occurring services constitutes this intentional act.
What is fraud.
In a hospital setting, this report, completed by the care provider, details the reason the patient is being admitted and results of a physical exam.
What is H&P
Information that identifies a patient in any way is known as _____________.
What is protected health information
This type of EHR allows patients to access their own health record via the Internet.
What is a patient portal
This EHR function allows the user to assign or may automatically assign a "to-do" list for themselves or other staff members.
What is a task list
What type of data is a zip code?
What is structured data
the identification of the nature of an illness or other problem by examination of the symptoms is called _______
What is a diagnosis
The law that requires EMR's to be put in place
What is Patient Protection and Affordable Care Act (PPACA)
For insurance and quality care purposes, a procedure or service cannot be done without a valid medical reason, otherwise know as ________________.
What is medical necessity.
A unique identifier that is required on claim forms and identifies a care provider or group practice is know as ___________.
What is the National Provider Identifier number
This EHR feature is used to ensure that data is documented consistently.
What is the data dictionary
These are issued when one or more diagnostic or treatment directives are generated by a physician or physician assistant
What is an order
This law motivates implementation of EHRs
What is the HITECH act
Pulse Respiration Rate, Blood Pressure are all examples of _______
What is Vital Signs
This EHR feature gives healthcare professionals reminders about individual patients that they would not otherwise remember.
What is a flag
This type of report allows a staff member to filter the patients at that facility by areas such as diagnosis, age, and zip code without including any identifying information.
What is a custom report
A care provider is dictating a progress note while the patient is being seen. This term defines the time of occurrence.
What is point of care
This supports seamless and secure access, exchange, and use of electronic health information within EHRs
What is ONC’s Cures Act
This helps improve medical practice management by increasing practice efficiencies and cost savings
What is Electronic Health Records