Stack #615300 Word Scramble

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Question	Answer
A health record is considered	C. Both A and B
A medical report is a	D. Both A and C
The key to substantiating procedure and diagnostic code selections for proper reimbursement is	B. supporting documentation in the health record
The chronologic recording of pertinent facts and observations about the patient's health is known as	C. Documentation
Reasons for documentation are	C. Both A and B
The SOAP in patient medical record charting may be defined as	B. Subjective, Objective,Assessment, Plan
When a patient fails to return for needed treatment, documentation should be made	D. All of the above
How should an entry in a patient's medical record be corrected?	A. Cross out the incorrect entry, substitute the correct information, date and initial the entry
A concise statement describing the symptom, problem, condition, diagnosis, physician-recommeneded return, or other factor that is the reason for the encounter is abbreviated as?	A. CC
Levels of evaluation and management services are based on types of physical examination that may be	C. Problem focused
An expanded problem-focused examination is a/an	C. limited examination of the affected body area
The official American Hospital Association policy states that abbreviations should be totally eliminated from the more vital sections of the record, such as the	D. All of the above
A diseased condition or state is known as	B. Morbidity
What does comorbidity mean?	C. Underlying disease or other conditions present at the time of visit.
A new patient is one who?	C. Has not received any professional services from the physician within the past 3 yrs
An established patient is one who?	B. Has previously recieved professional services from a physician or another physcian of the same specialty within the last 3 years
In dealing with managed care plans, a referral is?	D. Both B and C
Your physician has been to the hospital providing constant bedside attention and treating a patient in respiratory failure. These services are considered?	B. Critical Care
When a discussion takes place with a patient concerning the risks and benefits of treatment options it is considered?	C. counseling
Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the?	C. right lower quadrant
Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as?	C. Intermediate
The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading	A. simple
A review of patient records done before billing is submitted is called?	B. prospective
Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime.	A. exclusion from program participation is mandatory
Which of the following cases should not use fax transmission?	D. All of the above
Who may accept a subpoena?	C. Both A and B
Preservation of health records is governed by?	Both B and C
Records that must be retained indefinitely include	C. patient's medical records, x-ray films, and inactive patient's medical records
Social changes as well as medical specialization have altered what needs to be done with patient's medical records.	A. True
The acronym HIPAA stands for?	D. health Insurance Portability and Accountability Act
In 2000 congress appropiated 50 million to ---- to support a variety of efforts targeted at reducing medical errors	A. AHRQ
As many as ___ people die in hospitals each year as a result of medical errors that could have been prevented	D. 98,000
CPOE is an acronym for	B. computerized physician Order entry
SOAP is an acronym for	D. subjective, objective, assessment, plan
The concept of computerizing a patient's medical record has been around for?	A. 30 years
A study by the Center for Information Technology Leadership found more than 130,000 life threatening situations caused by adverse drug reactions	A. True
The IOM put forth a set of___ core functions that an EHR should be capable of performing	A. 8
A laboratory requisition records information about the patient, the clinician, and the___	B. test to be performed
IOM stands for?	A. Institute of Medicine of the National Academies
DAW is a pharmacy acronym for?	D. dispense as written
The simplest example of health maintenance is a card or letter remindind the patient that it is time for a check up	A. True
EHR is an acronym for electronic Health record	A. True
___are used to look up drugs by names or therapeutic classes	A. Drug formularies
The goal of the EHR is not to eliminate paper charts, but rather to eliminate paper charts being the only form of chart used	A. True
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	D. health level seven
Which of the following is not one of the core functions of the EHR set by the IOM?	C. paper support
The father of the problem-oriented chart was?	C. Dr. Lawrence Weed
Drawbacks to paper records includ the fact that they are?	D. B and C
AHRQ is an acronym for	A. Agency for healthcare research and quality
Which of the following is not one of the three key criteria identified by the computer-based patient record institute?	C. institute universal abbreviations
The new position established in an Executive Order signed by President Bush in 2004 was____	A. National Coordinator for Health Information Technology
The IOM study focused on medical erors occurring is hospitals, but other studies showed an even larger number of medical errors occurring in___	C. outpatient facilities
AHRQ is an acronym for	A. Agency for healthcare Research and quality
CPRI stands for___	A. computer-based Patient Record Institute
DUR is an acronym for?	C. Drug utilization review
HIPAA was passed by congress in___?	A. 1996
A new staff position that some clinics may choose to utilize with the use of EHR is?	C. Medical Scribe
A(n)___is a term used in an EHR for a message or reminder that is automatically generated from the data	A. alert
Medical vocabulary used in an EHR should be codified because there are so many	B. words that mean the same thing
MRI is an acronym for medical record initiative	B False
HIT is an acronym for?	B. Health information Technology
the concept of computerizing a patient's medical record has been around for about 50 yrs	B. False
EHR is an acronym for ?	B. Electronic health Record
NOC is an acronym for?	D. Nursing Outcomes Classification
The newest revision of the ICD-9 is the ICD-10 and it was released by the WHO in 1992	A. True
Which volume of the ICD-9 is used to bill for hospital procedures?	C. 3
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?	C. fielded data
Current Procedural Terminology was created in?	A. 1968
EHR users tend to locate findings by the ___, not the code	C. description
PCDS has more components than the Omaha System?	A. True
The ICD-9CM currently is published in___volumes	C.3
What is the code set designed for documenting nursing interventions in any clinical setting?	D. Nursing Interventions Classification
NIC stands for nursing interventions classification and is a code set designed for documenting nursing interventions in?	D. any clinical setting
___provides a universal coding system for mapping laboratory tests and results to a common terminology in the EHR	A. LOINC
Which of the following is not one of the ways that patient records can be stored?	A. protected data
NOC can be used to measure?	D. All of the above
The FDA began maintaining a list of all drugs prepared or sold by registered drug companies in___	A. 1973
CMS is an acronym for?	D. centers for medicare and Medicaid Services
Each drug product listed by the FDA is assigned a unique___digit number	C. 10
Which of the following is not a domain in the system of nursing interventions classifications?	A. education
PCDS stands for Patient Care Data Set and was developed by physicians at Harvard	B. False
Health and human services and the dept of defense and vetrens affairs agreed to endorse a set of standards in?	d. 2004
The largest number of LOINC codes are in the ___section	a. LABORATORY
To bill for a patient who is not sick, the ICD-9 code would start with the letter?	c. v
NANDA states that "A clinical judgement about individual, family, or community response to actual or potential health problems/life processes is a(n)	A. nursing diagnosis
When a code is stored in the medical record in addition to thee text description, the record is considered codified	A. True
HCPCS codes were created for billing	B. supplies, injectable medications, and blood products
CPT codes were created by the American Medical Association	A. True
How many standards are recognized by the north american nursing diagnosis association for use in the assessment, diagnosis, interventions, and outcomes of nursing care?	C. 13
Nomenclature is from a latin term and means?	C. a list of names
ICD-10PCS has been proposed to replace	B. ICD-9 volume 3
A code set designed specifically to record medical observations is often referred to as a clinical	D. nomenclature
___ in the EHR are automatic messages to the clinician or other staff person	D. Alerts
International classification of disease codes are maintained by the	C. World Health Organization
The Omaha system is made up of ___components	C. 3
FDA is an acronym for	C. Food and Drug Administration
Which of the following is not a category of medcin?	A. prognosis
CPT-4 codes were adopted by the government in?	C. 1983
Lab tests are a good example of codified data	A. true
What are the three portions of LOINC?	A. laboratory, clinical, and HIPAA
EHR nomenclatures need to have alot more codes to describe the details of the exam, for this reason they are said to be	B. granular
The standard identifier for human drugs is?	C. NDC
There are___different code sets offically recognized by the american nurse association	D. 13
A nomenclature is a system of names used in a field of science, typically created by a recongnized group or authority	A. True
SNOMED is an acronym for Selected Nomenclature of medicine	B. false
In medicine there is only one way to describe a symptom, condition, or observation	B. False
Which is not one of the components of the Omaha system?	B. problem updating area
The omaha system is a standardized terminology recognized by the american nurses association	A. true
Health and human services and the dept of defense and veterans affairs agreed to endorse a set of ___ standards	D. 20
In the term rheumatoid, the root rheumat means?	A. discharge
In the term phosphorus, the root phos means?	A. light
A sutural or__ bone is found between the flat bones of the skull?	A. wormian
The process of bending a limb is called?	A. flexion
In the term arthroscope, the suffix-scope means?	D. instrument
A condition that is characterized by the progressive loss of bone density and thinning of bone tissue is called	B. osteoporosis
A lateral curvature of the spine is known as?	C. scoliosis
The prefix dis- means	C. apart
In the term cartilage, the root cartil means	C. gristle
In the term chondrocostal, the root cost means	B. rib
In the term meniscus, the root menisc means	D. cresent
In the term cartilage, the suffi-age means?	A. related to
All of the following are classified as long bones except?	B. vertebrae
All of the following are functions of the skeletal system except?	A. acid-base balance
The membrane that forms the covering of bones except at their articular surfaces is called?	A. periosteum
A disease that involves inflammation of the joints is called?	A. arthritis
What structure is narrow passageway about as big around as ones thumb and located on the palm side of the wrist?	C. Carpal tunnel
The medical word for pertaining to the lower jawbone?	C. mandibular
The medical word for pertaining to the elbow is?	D. olecranal
The medical term for the big toe is	D. Hallux
A___fracture occurs at the ankle and affects both bones of the lower leg	A. Potts
Inflammation of the bone and joint is	B. osteoarthritis
The medical term for the heel bone is	A. calcaneus
the medical term for a fingerprint is?	B. dactylogram
Which bone is not located in the upper extremity?	D. femur
The medical term for knock-knee	D. gene valgum
Abnormal anterior curvature of the spine is called	D. lordosis
The ____ is the shaft of long bone	C. diaphysis
An opening in the bone for blood vessels, ligaments, and nerves is called	C. forearm
Bending a limb is called?	D. flexion
Lying with the face upward is called?	D. supination
An open fracture is called	B. compound
A condition of stiffening of ajoint is?	A. ankylosis
The bones of the wrist are called?	C. carpals
A diagnostic examination of a joint whee air and then a radiopaque contrast medium are injected into the joint space	C. arthrography
The process of recording heat patterns of the body's surface is called?	C. thermography
Which substance is increased i gout, arthritis, myeloma,rheumatism	C. uric acid
the ___ level in the blood may be increase in osteomalacia and fracture healing	C. alkaline phoshatase
which substance/s is/are present in a variety of immunologic diseases?	A. uric acid
Swayback is another word for?	D. lordosis
The solid matter in bone is known as	C. osseous tissue
All of the following are functions of bone except	D. hormone production
An articulation refers to a(n)?	D. joint
A rounded process that enters into the formation of a joint is	B. condyle
Synarthrosis is a type of joint	C. does not permit movement
Example of an amphiarthrosis joint is the	B. vertebrae
The process of moving a baody part away from the middle is	B. abduction
The suffix in flexion means	C. process
The cervical curve consists of ___ vertebrae?	B) 7
the center for longitudinal bone growth in childern is	D. Epiphyseal plate
The daily recommeneded amount of calcium for age 12 is	A. 1300 mg
Women build bone until about age?	D. 35
A term to describe loss of bone mass is	B.osteoporosis
The combining form in achondroplasis means?	C. cartliage
The term ankylosis means?	A. condition of stiffening of a joint
The combining form in calcaneal means?	D. heel bone
A term that means humpback is?	C. kyphosis
The suffix in lumbodyynia means?	D. pain
The term myelopoiesis means?	B. formation of bone marrow
The term used to describe softening of the bone is?	B. osteomalacia
The combining form in rachigraph means?	C. Spine
Drugs that can be used for skeletal system diseases and disorders include	D. all of the above
An abnormal lateral curvature of the spine is?	D. scoliosis
A___fracture usuallyoccurs in childern?	B. greenstick
Which fracture occurs at ankle and affects both bones of the lower leg?	B. Pott's
The surgical puncture of a joint for removal of fluid is?	C. arthrocentesis

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