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CHAPTER 6
MEDICAL BUSSINESS OPERATIONS
| Question | Answer |
|---|---|
| a drug or substance regulated by the government | controlled substance |
| used to measure blood pressure. | vitals cuff |
| department of a hospital cares for patients who have cancer | oncology |
| All software that contains e-PHI must have a___ or ___ to report who has viewed a patient’s information | tracking, auditing system |
| Schedule _____ of controlled substances is described as “high potential for abuse, may lead to severe psychological or physical dependence.” | II |
| Cough preparations containing less than 200 milligrams of codeine per 100 milliliters or grams fall into Schedule _____. | III |
| Trauma level ________ means the center provides initial evaluation, stabilization, and diagnostic services. Patients are transferred to a higher level of care facility when needed. If not open all hours, the trauma center must have an after-hours response | V |
| _______ is an imaging process that shows soft tissue using high-frequency sound waves and echoes | Ultrasound |
| ________ is an imaging process that creates an image of the body or function of an organ using a radioactive tracer. | Positron emission tomography (PET) |
| A(n) ____________ is a test that measures the frequency of brain waves. | Electroencephalogram |
| ______ is a coding system maintained by the American Medical Association to represent procedures or treatments offered by healthcare providers | Current procedural terminology |
| Which of these is an information system designed to store and retrieve different formats of medical imaging in one location, as well as communicate with other information systems? | Picture archiving and communication system |
| Which of these is a widely used file format developed by Adobe Systems used to present digital documents in a printable view on a monitor? | Portable document format |
| Which of these translates printed lettering into pure text that can be searched and manipulated on a computer? | Optical character recognition (OCR) |
| A(n) _________ is a version of a patient’s record for transferring relevant data? | Continuity of care document |
| A(n) ___________ is the interface pipeline that connects two information systems | Thread |
| The HL7 segment with order information that contains observation request is ______. | OBR |
| A(n) _______ is a connection point to an IS. | Node |
| Which of the following centralizes all medical images for search and retrival? | DICOM |
| Image file format that supports data compression and animation | Graphics interchange format |
| Healthcare industry standard for medical digital imaging, designed specifically for image handling, storing, printing, or transmitting | Digital imaging and communication in medicine |
| File format developed by Adobe Systems used to present digital documents in a printable view on a monitor | Portable document format (PDF) |
| Medical terminology standard used internationally to create consistency in keywords in medical documentation | Systemized nomenclature of medicine – clinic terms |
| Data about data | Metadata |
| Schedule I | No accepted medical use |
| HL7 segment for insurance information | IN1 |
| Translates printed lettering into pure text that can be searched and manipulated on a computer | Optical character recognition (OCR) |
| Stores and retrieves different formats of medical imaging in one location | Picture archiving and communication system |
| Device used to measure blood pressure | Vitals cuff |
| Term used in healthcare to express urgency | Stat |
| Primary care physician (PCP) | Ongoing relationship with patient |
| Required to have a residency program | Level I trauma center |
| Immediate intervention | Code blue |
| Between critical care unit and general nursing unit | Stepdown |
| Transmitted to pharmacy | e-prescribing |
| We all looked at that celebrities record | Audit trail |
| Unstructured documentation | Free text |
| Change management | (CAB) change advisory board |
| Imaging without radiation or injection | Ultrasound |
| Used primarily for encoding diagnoses and the resultant billing. | (ICD-10) |
| ICD-10 | International Classification of Diseases, Tenth Edition |
| CPT | Current Procedural Terminology |
| a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. | CPT |
| a systematic, computer-processable collection of medical terms | SNOMED-CT |
| SNOMED-CT | Systematized Nomenclature of Medicine |
| Common Physicians Roles in a Hospital | Admitting, Attending, Consulting |
| List some places in a large hospital that would have their own scheduling software – integrated of course into the HIS | Housekeeping, Surgery, Lab, Imaging |
| the collection of patient information from all visits at one hospital | EMR |
| collection of patient information from all hospitals the patient has visited. | EHR |
| the level of care that a patient requires | Patient acuity |
| a mobile X-ray machine that is small enough to be rolled to a patient’s room. | portable X-ray machine |
| an image taken of soft tissue using high-frequency sound waves and echoes | ultrasound |
| imaging that uses X-rays along with computing algorithms | computed tomography (CT) |
| CT | computed tomography |
| MRI | Magnetic resonance imaging (MRI) |
| imaging that uses strong magnetic fields and radio signals to create an image of a patient’s body. | Magnetic resonance imaging (MRI) |
| PET | positron emission tomography |
| imaging that creates an image of the body or function of an organ using a CT scan with a radioactive tracer | positron emission tomography (PET) |
| measures blood glucose levels | glucose monitor |
| measures the frequency of brain waves | electroencephalogram (EEG) |
| EEG | electroencephalogram (EEG) |
| tests for problems with the electrical activity of the heart | electrocardiogram (EKG or ECG) |
| determines the capability of veins to return blood from the lower limbs to the heart. | vascular stress test |
| used to diagnose and treat some heart disorders | nuclear stress test |
| test combines two PET scans before and after a vascular stress test. | nuclear stress test |
| A doctor uses a_____ to enter orders for a patient. | computerized physician order entry (CPOE) |
| used in several different departments of a hospital to schedule services offered | Scheduling software |
| used to follow and record patient flow through a patient’s changing medical status, lab studies, imaging, or other diagnostic and treatment services | Patient tracking software |
| software tracks the physical location of a patient in a hospital using radio frequency | radio frequency identification (RFID) technology |
| RFID | radio frequency identification (RFID) technology |
| software facilitates the creation, duplication, and safety of orders given by healthcare providers. | Order entry (OE) |
| OE | Order entry |
| software to electronically write a prescription for a patient | e-prescribing |
| an all-encompassing software solution to manage both clinical and business needs in a small- to medium-sized medical office, such as a physician’s practice or an outpatient medical office. | Practice management software |
| receives data from a patient’s EHR or EMR, converts the data into billable items, and submits the bill to the insurance company for reimbursement | Billing and coding software |
| codes describe diagnosis or classification of diseases or illnesses | ICD-10 |
| the standard in the medical field for saving digital images. | Digital imaging and communication in medicine (DICOM) |
| DICOM | Digital imaging and communication in medicine |
| centralizes all the different types of medical images into one information system, stores and retrieves medical images, and communicates medical images with other information systems. | Picture archiving and communication system (PACS) |
| PACS | Picture archiving and communication system |
| program scans an image and translates the text from the image into pure text that is searchable. | optical character recognition (OCR) |
| data about the data that acts like tags containing keywords, such as a patient’s MRN, to make searching for a specific file faster and easier | metadata |
| also called change control, is a process to define a change needed, the steps to take to complete it, the results of the change, and the timeframe for completion | Change management |
| responsible for approving pending change management requests | change advisory board (CAB), or governance board |
| Four IS environments used during the change management process are | development, QA/test, user test, and production/live |
| provides an easily transferred snapshot of a patient’s record, which can be easily read by a person or by an IS | continuity of care document (CCD) |
| CCD | continuity of care document |
| a collection of CCDs, spanning multiple patient visits, sometimes called patient encounters | continuity of care record (CCR) |
| CCR | continuity of care record |
| The ______ is usually the first physician a patient sees when he experiences a new illness or medical condition and for regular checkups. | PCP |
| A ______ is imaging that creates an image of the body or function of an organ using a _____ scan with a radioactive tracer. | PET, CT |
| An _____ or _____ tests for problems with the electrical activity of the heart. | EKG or ECG |
| The _____ cares for preterm babies. | NICU |
| The _____ provides general care for adult patients in a hospital. | MED/SURG |
| The _____ cares for patients leaving the OR as the anesthesia wears off. | PACU |
| The ______ is a code assigned to each drug used by the FDA to maintain a list of drugs being produced. | NDCID |
| _____ codes justify billing the _____ codes. | ICD-10, CPT |
| ______ technology translates several ways to describe the same medical term into a single code. | SNOMED-CT |
| Every ______ message contains an ______ segment that contains information about the message type and date/time stamp. | HL7, MSH |
| What is the difference between an EMR and an EHR? | EMR is the collection of patient information from all visits at one hospital, EHR is the collection of patient information from all hospitals the patient has visited |
| What does a healthcare provider mean when he orders a medication to be given “stat?” | medication should be given immediately |
| Which level trauma center is most equipped to care for a trauma patient because the facility has a full range of specialists and equipment available at all times? | Level I |
| Why might a physician order a CT scan over an X-ray for a patient? | CT machine produces an image with 100 times more clarity than normal Xray imaging |
| Why must all employees, including HIT personnel, be careful when entering a room with an MRI machine present? | Absolutely no metal must enter the room because it can cause a dangerous situation as the magnetic field pulls the object to the machine. |
| What is the difference between obstetrics and gynecology (OB/GYN)? | Obstetricians care for women who are pregnant, and gynecologists care forwomen at any other time |
| Which inpatient department cares for adolescents? | Pediatrics (PEDS) |
| What service does occupational therapy (OT) offer? | offers rehabilitation to disabled patients to restore meaningful and purposeful activities of daily living |
| What is the purpose of nuclear medicine? | deals with the use of radioactive substances for diagnosis, treatment, and research of medical conditions |
| What type of information might a patient give during registration? | Full name Address Employer Next of kin Billing and insurance information Referring and family physician information |
| How might computerized physician order entry (CPOE) be different from the order entry IS that nurses use? | customized to the doctor’s needs because it has the capability to enter prescriptions |
| How is scheduling software specifically designed for healthcare use? | offer conveniences, such as reserving rooms, procedures, and personnel based on the type of procedure or service |
| What are two types of patient tracking software? | patient’s changing medical status, RFID) |
| Explain the difference between ICD-10 codes and CPT codes. | ICD-10 codes justify billing the CPT codes |
| What services does a healthcare clearinghouse offer? | collects the CPT codes and gives the codes a monetary value |
| What is the standard file format in the medical field for saving digital medical images? | digital imaging and communication in medicine (DICOM) |
| What is the technology that translates printed lettering from a scanned image into pure text that can be searched and manipulated on a computer? | optical character recognition (OCR) |
| Why is it important to consider the time of day to implement a change when creating change management documentation to be submitted to a CAB for approval? | downtime, choosing off hours might be best to decrease the number of healthcare providers who will be affected |
| What is the difference between a continuity of care document and a continuity of care record? | Many CCDs can make up a CCR. |
| What symbol in an HL7 segment separates fields? What does it mean when two symbols are side by side with nothing in between them? | The vertical bar | separates each field. Two vertical bars together indicate the field is present, but contains no data |
Created by:
Wynston
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