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EMR 2
| Question | Answer |
|---|---|
| Role of the Front Office Assistant | *Positive attitude *Greeting patients on the phone and in person * Creating and managing an EHR for each patient * Generating patient letters and other correspondence * Providing patient education material |
| Communication in the Medical Office | *reduces staff turnover rates *Prevents medical errors * Good communication decreases likelihood of lawsuits * STAFF ENCOUNTERS ARE IMPORTANT IN MAKING THE PT FEEL VALUED & COMFORTABLE |
| No shows | people who do not show up or call to cancel |
| Ways to reduce number of No Shows in office | *charge * call to confirm * call afterward *Establish relationship * Have a "quick call list" * see patients on walk-in basis only * double book |
| Encryption technology | is HIPAA approved |
| Faxes | *Can be misdirected because of human error * faxes are difficulty to verify that all pages were received |
| Eliminating Duplicate Charts | *ask whether the patient has ever been seen by the practice before * ask established patients if they have had a name chang *always set up the patient EHR account using the name listed on the insurance ard |
| Active | seen within 3 years |
| inactive | not seen within 3 years |
| closed patient | have terminated relationship |
| purging | process of removing inactive and losed patient health records from those that are active |
| Backing up of Electronic Health Record | Offices must have a written backup and recovery plan in place (HIPAA) *once daily offsite location - laptop purchased through a vendor |
| CMS 1500 | a universal claim form used by govt. standardized |
| A standardized way of assigning standard numeric or alphanumeric codes to diagnoses, procedures, and treatments for reimbursement purposes | Medical coding |
| International Classification of Diseases, Ninth Edition, with Clinical Modification (ICD-0-cm) | Diagnosis codes |
| current Procedural terminology, fourth edition (CPT-4) | procedure codes |
| A period of time reserved for a patient to see a healthcare provider | appointment slot |
| Giving two or more patients the same appointment time with the same provider | double-booking |
| A system that keeps data secure by converting it into an unreadable code during transmission and then encrypting the information when it reaches the recipient | encryption technology |
| A fax transmission sent via secure e-mail | secure fax |
| A series of e-mails on a single topic | message string |
| A product of accurately estimated patient volume, a consistent provider pace, and efficient scheduling practices | patient flow |
| The process of separating inactive patient health records from active ones | purging |
| The period of time patient records must, by law, be maintained by the medical office | retention |
| A system capable of transmitting an encrypted message and storing it in coded format until it is retrieved by the recipient via a secure web link | secure e-mail |
| The percentage of patients in a practice who arrive for appointments as scheduled or call in advance to cancel or reschedule | show rate |
| A polite, helpful response and respectful manner towards callers | telephone etiquette |
| E-mail recipients who receive copies of the same message but whose names are not visible to one another | undisclosed recipients |
| different ways of displaying the same or similar information on a computer screen, usually with increasing or decreasing detail | views |
| The first stop in a patient's path through the medical office | waiting room |
| mistake in coding. caused by computer error , human error of various sorts, ranging from simple carelessness to incorrect application of coding guidelines and procedures | coding variances |
| Intentional misrepresentation of serices to deceive or mislead | fraud |
| unintentional deception in which a provider inappropriately bills for services that are not medically necessary or do not meet current standards of care | abuse |
| ICD -9-CM coding | international classification of diseases |
| V codes of the ICD -9- CM coding | wellness codes |
| E codes of the ICD -9- CM coding | external cause of disease |
| the person who is responsible for the account | guarantor |
| A legal doctrine which holds that medical services rendered must be reasonable and necessary according to generally accepted clinical standards | Medical Necessary |
| makes diagnosis & treatment more efficient * reduces medical errors * serves as a risk-management function * legal evidence | documentation in the electronic health record |
| offered only to established patients only * patient must initiate the process and agree to the terms of serice *must occur via HIPAA-compliant online connection * document the e-visits like any other visit * | E-Visits |
| when patient care is transferred | referral |
| when doctor request advice or opinion from another professional | consultation |
| P* Past Medical and Surgical History *F - family history: genetic/inherited diseases *S* Social history - patient liing situation, habits, drugs, etc *May also contain ROS (review of systems) | PFSH (documenting patient history |
| patient living situation, habits, smoking, drugs | social history |
| Chief complaint - the patient's main reason for seeking medical care | CC |
| symptoms * duration * chronology - Have the symptoms been persistent or intermittent? * alleviation or exacerbation - what makes the symptoms better or worse? | HPI (History of Present Illness) |
| temperature, B/P, pulse, and respirations | vital signs |
| S: Subjective - what the patient tells you * O: Objective - information which can be observed, measured, or collected (vital signs) * A: Assessment - summation of the diagnosis or the impression of what's wrong ith the patient * P: Plan - steps the provid | The Progress Note |
Created by:
peidismith