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CODE NAMES
EHR
| Question | Answer |
|---|---|
| HCPCS | Healthcare Common Procedural Coding system |
| What is the HCPCS used for? | LE VEL 1 : the services of the provider codes LEVEL 2 : the supplies and equipment of service |
| CFO | Chief Financial Officer |
| all financial and fiscal decisions are to be discussed with? | CFO |
| CCR | Continuity of Care Record |
| makes it possible to integrate external and internal in electronic health records | CCR |
| CCD | Continuity of Care Document |
| which system replaced CCR? | CCD |
| CCHIT | Certification Commission for Health Information Technology |
| Certifications of EHR/EMR come from..... | CCHIT |
| HITECH | Health Information Technology for Economic and Clinical Health (Act) |
| encourages adoption of EHR with commissions | HITECH |
| PCU | Patient Care Unit |
| a general census of patients in the hospital (helps decide clinical schedules) | PCU |
| NCVHS | National Committee on Vital and Health Statistics |
| name on of the national data warehouses | NCVHS |
| C.D.C | Center of Disease Control and Prevention (no P) |
| division in the Department of Health and Human Services | CDC |
| NCHS | National Center of Health Statistics |
| primary statistics organization on health to guide and influence health policy and practice to best serve the population | NCHS |
| NAMCS | National Ambulatory Medical Care Survey |
| who collects data on outpatient services in provider offices and clinics? | NAMCS |
| ALOS | Average Length of Stay (O in of included) |
| a count of days that a patient has stayed | ALOS |
| PPS | Prospective Payment System |
| pay based on original diagnosis of the patient | PPS |
| PDR | Physicians Desk Reference |
| Database of medications and manufactures, as well as prescribing info | PDR |
| NPDB | National Practitioner Data Bank |
| what is the name of the database of physicians? | NPDB |
| Why would you use the NPDB? | To help define the scope of practice for any one specific physician |
| Privacy Rules (HIPAA) | helps to understand when info can be shared for patient care and business purposes |
| Security Rules (HIPAA) | General protection of PHI (physical, administrative, and technical safeguards) |
| What is the difference between security and privacy? | Privacy will protect PHI with an understanding of when and what can be shared, whilst security protects PHI in general |
| MPI | Master Patient Index |
| a record of every patient that had been treated, seen, evaluated in a facility and must forever be maintained | MPI |
| Fully integrated EHR | replaced paper records entirely |
| HIS | Hospital Information System |
| storage, collection, manipulation (addendums) and management of data generated in daily operations | HIS |
| WOW | Wireless on wheels |
| used generally to collect patient info and has a barcode scanner, this acronym is used instead of COW | WOW |
| Medical terminology | language of medicine, has more than one dictionary |
| CPT | Current Procedural Terminology |
| a naming system | CPT |
| ICD-9-CM | International Code of Diseases, 9th revision, Clinical Modifications |
| contains many codes, organized with I or O to prevent number confusion | ICD-9-CM |
| Volume 1 | Tabular list of disease and injuries |
| Volume 2 | The alphabetic index to disease and injuries |
| Volume 3 | The Classification for Procedures and reporting hospital procedures |
| V-Codes | codes used to classify visits when there are other circumstances than disease or injury are the reason for the appointment |
| E-Codes | Codes used to classify causes of injury, poisoning, other adverse events |
| Practice Management System | Software designed to assist office workflow |
| Third party Vendor | Billing company, transcription companies, and coding firms |
| Encounter Forms | form filled out by provider containing service charges, how much had been already paid (used for bills) |
| E & M | Evaluation and Management codes |
| time provider spent in treating a patient. | E & M |
| SNOMED-CT | SYSTEMIZED Nomenclature of Medicine- Clinical Terms |
| medical vocab that standardizes the naming of medical/health care terminology | SNOMED-CT |
| Medical Staff Committee | committee formed to discuss and recommend practices, policies, and other activities specific to staff |
| Med Rec | Medication Reconciliation |
| what is it called when you gather and document a patients list of meds, including new ones and current ones | Med Rec |
| ePrescribing | software used by providers to electronically prescribe medication to a patient; is sent to pharmacy |
| RBACs | Role-Based Access Controls |
| controls the ability to access certain areas of the system based on the person roles | RBACs |
| CPT codes | Current Procedural Terminology codes |
| numeric codes developed by the American Medical Association (AMA) to standardize medical services/procedures | CPT codes |
| EHR | Electronic Health Records |
| data created, managed, consulted by clinical staff WITHIN ONE health care organization | EHR |
| EMR | Electronic Medical Records |
| data created, managed, consulted by clinical staff ACROSS more than one health care organization | EMR |
| Interoperability | capacity of systems to communicate and exchange information with one another |
| Standards Organizations | Government agencies, Voluntary groups, and industry associations involved in establishing guidelines to assist uniformity |
| data repository | electronic holding place for data |
| Examples of standards organizations I | American National Standards Institute (ANSI) Accredited standards committee X12 (ASC X12) |
| Examples of Standards organizations II | The American Society for Testing and Materials (ASTM) Digital Imaging and Communications in Medicine (DICOM) |
| Examples of Standards Organizations III | Health Level 7 (HL7) National Council for Prescription Drug Programs (NCPDP) |
| CPOE | Computerized Provider Order Entry |
| Providers use this to order medication, IV Therapies, lab tests, imaging studies, rehabilitation services, Dietary requirements | CPOE |
| Joint Commission (TJC) | The Joint Commission on the Accreditation of Health Care Organizations |
| independent organization that accredits/certifies more than 19,000 hcf/programs in the US, recognized as gold standard | TJC (Joint Commission) |
| CMS | Centers for Medicare and Medicaid Services |
| charged with administration of Medicare/ Medicaid programs as well as children's health insurance | CMS |
| H & P | History and Physical |
| required to be filed into inpatient record with 24 hrs, and cannot be more than thirty days old | H & P |
| interoperability | the capacity of systems to communicate and exchange information with one another |
| standards organizations | government agencies, voluntary groups, and industry associations that establish guidelines for efficiency |
| data repository | electronic holding place for data |
| reminders | automated notices to practitioners or patients regarding actions that need to be taken |
| alerts | automated notices to practitioners of info that requires immediate or special attention |
| treatment protocols | established guidelines for treatment of specific diseases |
| telemonitoring | using telecommunications technology to gather physiologic or diagnostic data and transmit to health care providers |
Created by:
awierman20
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