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