Stack #615300
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A health record is considered | show 🗑
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A medical report is a | show 🗑
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The key to substantiating procedure and diagnostic code selections for proper reimbursement is | show 🗑
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show | C. Documentation
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Reasons for documentation are | show 🗑
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show | B. Subjective, Objective,Assessment, Plan
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show | D. All of the above
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show | A. Cross out the incorrect entry, substitute the correct information, date and initial the entry
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show | A. CC
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Levels of evaluation and management services are based on types of physical examination that may be | show 🗑
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An expanded problem-focused examination is a/an | show 🗑
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The official American Hospital Association policy states that abbreviations should be totally eliminated from the more vital sections of the record, such as the | show 🗑
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A diseased condition or state is known as | show 🗑
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show | C. Underlying disease or other conditions present at the time of visit.
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A new patient is one who? | show 🗑
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show | B. Has previously recieved professional services from a physician or another physcian of the same specialty within the last 3 years
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In dealing with managed care plans, a referral is? | show 🗑
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show | B. Critical Care
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show | C. counseling
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show | C. right lower quadrant
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Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as? | show 🗑
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The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading | show 🗑
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A review of patient records done before billing is submitted is called? | show 🗑
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show | A. exclusion from program participation is mandatory
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Which of the following cases should not use fax transmission? | show 🗑
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show | C. Both A and B
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Preservation of health records is governed by? | show 🗑
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show | C. patient's medical records, x-ray films, and inactive patient's medical records
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Social changes as well as medical specialization have altered what needs to be done with patient's medical records. | show 🗑
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show | D. health Insurance Portability and Accountability Act
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show | A. AHRQ
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As many as ___ people die in hospitals each year as a result of medical errors that could have been prevented | show 🗑
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CPOE is an acronym for | show 🗑
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show | D. subjective, objective, assessment, plan
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show | A. 30 years
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A study by the Center for Information Technology Leadership found more than 130,000 life threatening situations caused by adverse drug reactions | show 🗑
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show | A. 8
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show | B. test to be performed
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show | A. Institute of Medicine of the National Academies
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DAW is a pharmacy acronym for? | show 🗑
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The simplest example of health maintenance is a card or letter remindind the patient that it is time for a check up | show 🗑
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EHR is an acronym for electronic Health record | show 🗑
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show | A. Drug formularies
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show | A. True
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A non-profit org, that developed and maintains the leading messaging standard used to exchange clinical and administrative data between different health care computer systems is | show 🗑
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show | C. paper support
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The father of the problem-oriented chart was? | show 🗑
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show | D. B and C
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AHRQ is an acronym for | show 🗑
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Which of the following is not one of the three key criteria identified by the computer-based patient record institute? | show 🗑
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show | A. National Coordinator for Health Information Technology
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show | C. outpatient facilities
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show | A. Agency for healthcare Research and quality
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CPRI stands for___ | show 🗑
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DUR is an acronym for? | show 🗑
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HIPAA was passed by congress in___? | show 🗑
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show | C. Medical Scribe
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A(n)___is a term used in an EHR for a message or reminder that is automatically generated from the data | show 🗑
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Medical vocabulary used in an EHR should be codified because there are so many | show 🗑
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show | B False
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HIT is an acronym for? | show 🗑
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the concept of computerizing a patient's medical record has been around for about 50 yrs | show 🗑
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show | B. Electronic health Record
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show | D. Nursing Outcomes Classification
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show | A. True
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Which volume of the ICD-9 is used to bill for hospital procedures? | show 🗑
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What way of storing information is the most common way to store in the EHR system and is fast, efficient, and uses very little storage space? | show 🗑
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Current Procedural Terminology was created in? | show 🗑
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EHR users tend to locate findings by the ___, not the code | show 🗑
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show | A. True
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The ICD-9CM currently is published in___volumes | show 🗑
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show | D. Nursing Interventions Classification
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show | D. any clinical setting
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___provides a universal coding system for mapping laboratory tests and results to a common terminology in the EHR | show 🗑
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show | A. protected data
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NOC can be used to measure? | show 🗑
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show | A. 1973
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show | D. centers for medicare and Medicaid Services
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Each drug product listed by the FDA is assigned a unique___digit number | show 🗑
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Which of the following is not a domain in the system of nursing interventions classifications? | show 🗑
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PCDS stands for Patient Care Data Set and was developed by physicians at Harvard | show 🗑
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Health and human services and the dept of defense and vetrens affairs agreed to endorse a set of standards in? | show 🗑
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show | a. LABORATORY
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show | c. v
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show | A. nursing diagnosis
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When a code is stored in the medical record in addition to thee text description, the record is considered codified | show 🗑
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HCPCS codes were created for billing | show 🗑
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CPT codes were created by the American Medical Association | show 🗑
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How many standards are recognized by the north american nursing diagnosis association for use in the assessment, diagnosis, interventions, and outcomes of nursing care? | show 🗑
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show | C. a list of names
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show | B. ICD-9 volume 3
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show | D. nomenclature
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___ in the EHR are automatic messages to the clinician or other staff person | show 🗑
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show | C. World Health Organization
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show | C. 3
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show | C. Food and Drug Administration
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Which of the following is not a category of medcin? | show 🗑
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CPT-4 codes were adopted by the government in? | show 🗑
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Lab tests are a good example of codified data | show 🗑
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show | A. laboratory, clinical, and HIPAA
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show | B. granular
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The standard identifier for human drugs is? | show 🗑
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There are___different code sets offically recognized by the american nurse association | show 🗑
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show | A. True
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show | B. false
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In medicine there is only one way to describe a symptom, condition, or observation | show 🗑
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Which is not one of the components of the Omaha system? | show 🗑
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The omaha system is a standardized terminology recognized by the american nurses association | show 🗑
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show | D. 20
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In the term rheumatoid, the root rheumat means? | show 🗑
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show | A. light
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show | A. wormian
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The process of bending a limb is called? | show 🗑
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show | D. instrument
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A condition that is characterized by the progressive loss of bone density and thinning of bone tissue is called | show 🗑
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A lateral curvature of the spine is known as? | show 🗑
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show | C. apart
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show | C. gristle
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In the term chondrocostal, the root cost means | show 🗑
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show | D. cresent
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show | A. related to
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show | B. vertebrae
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show | A. acid-base balance
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The membrane that forms the covering of bones except at their articular surfaces is called? | show 🗑
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A disease that involves inflammation of the joints is called? | show 🗑
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show | C. Carpal tunnel
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The medical word for pertaining to the lower jawbone? | show 🗑
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show | D. olecranal
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The medical term for the big toe is | show 🗑
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A___fracture occurs at the ankle and affects both bones of the lower leg | show 🗑
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show | B. osteoarthritis
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The medical term for the heel bone is | show 🗑
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the medical term for a fingerprint is? | show 🗑
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show | D. femur
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The medical term for knock-knee | show 🗑
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Abnormal anterior curvature of the spine is called | show 🗑
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show | C. diaphysis
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An opening in the bone for blood vessels, ligaments, and nerves is called | show 🗑
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Bending a limb is called? | show 🗑
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Lying with the face upward is called? | show 🗑
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An open fracture is called | show 🗑
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A condition of stiffening of ajoint is? | show 🗑
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The bones of the wrist are called? | show 🗑
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show | C. arthrography
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The process of recording heat patterns of the body's surface is called? | show 🗑
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Which substance is increased i gout, arthritis, myeloma,rheumatism | show 🗑
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show | C. alkaline phoshatase
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which substance/s is/are present in a variety of immunologic diseases? | show 🗑
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Swayback is another word for? | show 🗑
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The solid matter in bone is known as | show 🗑
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All of the following are functions of bone except | show 🗑
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An articulation refers to a(n)? | show 🗑
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A rounded process that enters into the formation of a joint is | show 🗑
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show | C. does not permit movement
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show | B. vertebrae
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The process of moving a baody part away from the middle is | show 🗑
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show | C. process
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The cervical curve consists of ___ vertebrae? | show 🗑
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the center for longitudinal bone growth in childern is | show 🗑
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show | A. 1300 mg
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show | D. 35
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show | B.osteoporosis
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show | C. cartliage
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The term ankylosis means? | show 🗑
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The combining form in calcaneal means? | show 🗑
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show | C. kyphosis
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The suffix in lumbodyynia means? | show 🗑
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The term myelopoiesis means? | show 🗑
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show | B. osteomalacia
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show | C. Spine
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Drugs that can be used for skeletal system diseases and disorders include | show 🗑
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An abnormal lateral curvature of the spine is? | show 🗑
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A___fracture usuallyoccurs in childern? | show 🗑
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show | B. Pott's
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The surgical puncture of a joint for removal of fluid is? | show 🗑
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