ch 4 medical documet
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| show | EMR
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| show | EHR
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| show | accessibility
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| show | 2.0
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| 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. | show 🗑
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| show | problem oriented record system (POR), source oriented record system (SOR), integrated record system
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| show | health record
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| what is the CMS definition of legible documentation? | show 🗑
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| 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 | show 🗑
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| show | walk in rights
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| a list of all staff members names, job titles, signatures, and their initials is known as | show 🗑
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| show | note section as error with date, time, enter correct info w/ notation of when and why the physician changed entry.
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| fro paper based records, how whould an error be corrected on a patients record? | show 🗑
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| if a medical practice is audited by medicare officials and intentional miscoding is discoverd, _____ and may belevied and providers may be _____. | show 🗑
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| when each entry in the medical record is worded similar to the previous entries this is considered | show 🗑
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| an electronic medical report is a | show 🗑
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| show | supporting documentation in the electronic health record
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| the chronological recording of pertinent facts and observations about the patient's health is known as | show 🗑
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| show | defense of a professional liability claim, insurance carriers require accurate documentation that supports procedure and diagnostic codes
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| the SOAP in patient medical record charting may be defined as | show 🗑
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| when a patient fails to return for needed treatment, documentation should be made | show 🗑
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Created by:
eg6791