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ch 4 medical documet
| Question | Answer |
|---|---|
| an individual physician record of the patients care | EMR |
| all of the patients records,from many different information systems and providers | EHR |
| the greatest advantage of an EHR system is the improvement of quality of care and patient safety through the ________ of medical records between providers and other health care organizations. | accessibility |
| providers who are not participating in the E- prescribing incentive plan in 2014 will have medical claimsprocessed with a ____ percent adjustment/reduction in their payments | 2.0 |
| stage 2 of the meaningful use incentive program will focus on _________ , which will expand the criteria in areas of disease management, clinical decision support, medication management, transition in care, quality measurement, and research. | advance clinical process |
| list three of the various types of health record systems that can be used in a medical practice | problem oriented record system (POR), source oriented record system (SOR), integrated record system |
| written or graphic info about patient care is termed a | health record |
| what is the CMS definition of legible documentation? | the data must be easily recognizable by someone outside of the medical practice who is unfamiliar with the handwriting |
| performance of services or procedures consistent with the diagnosis, donr with standards of good medical practice and a properlevel of care given in the appropriate setting is known as | medical necessity |
| medicare administrative contractors have ______ to access a medical practice without an appointment or search warrent to conduct a review of documentation, audits, and evaluations. | walk in rights |
| a list of all staff members names, job titles, signatures, and their initials is known as | signature log |
| for electronic health records, how should an insurance billing specialist correct an error on a patients record? | note section as error with date, time, enter correct info w/ notation of when and why the physician changed entry. |
| fro paper based records, how whould an error be corrected on a patients record? | mark w/ one line through, write correct info, date and initial it. |
| if a medical practice is audited by medicare officials and intentional miscoding is discoverd, _____ and may belevied and providers may be _____. | fines, excluded |
| when each entry in the medical record is worded similar to the previous entries this is considered | cloned documentation |
| an electronic medical report is a | permanent legal document, part of the health record |
| the key to substaining procedure and diagnostic code selections for proper reimbursment is | supporting documentation in the electronic health record |
| the chronological recording of pertinent facts and observations about the patient's health is known as | documentation |
| reasons for documentation are | defense of a professional liability claim, insurance carriers require accurate documentation that supports procedure and diagnostic codes |
| the SOAP in patient medical record charting may be defined as | subjective, objective, assessment, plan |
| when a patient fails to return for needed treatment, documentation should be made | in the patients medical record, in the appointment book, on the financial record or ledger card |
| how should an entry in a patients electronic medical record be corrected? |
Created by:
eg6791