Chapter 5- Managing Health Information

A standard version of a document that is used over and over again is...

A temple

Each office should have an...for equipment, time, and other resources, including the computer

Acceptable Use Policy (AUP)

A book of consecutive numbers indicating the next available number to be assigned

Accession book

Required for tax reporting and are critical for the practice's success

Accurate Financial Record

Offices using electronic medical record entry methods should...to all chart entries

Affix an Electronic Signature

P.C. means

After meals

There are ten rules for....

Alphabetic filing

Making corrections to a chart with an eraser or scribbling out entries could present the...

Appearance of Fraud

Includes word processing, graphics, spreadsheet, and database management software, applies the computer's capabilities to specific application

Application Software

A.C. means

Before Meals

Charting format breaks down the components of a patient encounter into seven detail-oriented sections

CHEDDAR

A chronological record of ongoing patient care and progress

Chart Note

When a patient has died, moved away, or terminated their relationship with the physician, the file is considered...

Closed

The placing of a number, letter, or an underscore beneath a word to indicate where the document should be filed

Coding

Easy to locate misfiled charts

Color Coding System

Policies and procedures for updating medical personnel and evidence of the training should be placed in the...

Compliance Manual

Abbreviations in medical documentation can lead to a vast array of...

Consequences

One of the most important task of an administrative medical assistant is the...

Creation of health insurance claims

An active file pertains to...

Current Patients

A tickler file should be consulted...

Daily

In a POMR, there are three essential components:

Database, Master Problem List, and Initial Plan

Records that have been closed and those that must be kept permanently are said to be in...separate from the area where active files are kept

Dead Storage

Information of use to only one staff member is stored in a... file convenient for the user

Decentralized

Do you use correction tape in an attempt to keep the entry neat due to an error?

Do not use

Does the federal law regulate retention time frames for patient's medical records?

Does not

It has been estimated that 80% of healthcare facilities and 50% of physician practices that have already implemented...

EHR

Dead storage need not be...

Easily accessible

What does the abbreviation EFT stand for?

Electronic Funds Transfer

what provides advantages over paper appointment books in a medical office schedule?

Electronic Maintenance

Another name for a central computer...

File Server

Five steps are included in...

Filing

Completely removing electronic date could give the appearance of...

Fraud

Centralized files and Vertical files are arranged from...

Front to Back

Laws have been passed and large sums of money have, and are being implementation of...

Healthcare reform

Mental process of selecting the name, title, or classification under which an item will be filed

Indexing

Patient have the right to...

Inspect their medical record

Lateral files are arranged from...

Left to right

What type of computer is used in large businesses, hospitals, large clinic, and government organizations?

Mainframe Computers

The best measurement of quality of care given to a patient is the...

Medical Record

Most medical billing offices use a medical billing program such as...

Medisoft

What has less power than a mainframe?

Mini Computers

Centralized files are kept in...

One place

Used to educate physicians's concerning conditions and treatment regimes

Online Medical Database

The need to conserve space in many offices has made...files popular

Open-Shelf

Save time and labor but isn't secure

Open-Shelf Files

The acceptable chart notation for "As needed" is...

P.R.N

There are 3 main types of records in the medical office:

Patient Medical Records, Correspondence related to healthcare, and practice management records

The central responsibility of the physician's practice is...

Patient care

The subjective findings are the...of the problem or the complaint

Patient's Description

Constitutes the legal record of the medical practice

Patient's Medical Record

Objective findings in a SOAP record are the...of the patient

Physician's Examination

All medical records should be kept until the...

Possibility of a malpractice suit has passed

After a patient encounter, the new electronic medical data should be...

Reviewed and proofread for errors

The most common method system for outlining and structuring chart notes for a medical record

SOAP Method

All chart notes must be...

Signed and dated

An Inactive file relates to patient who have not seen the physician for...

Six months

Designed to imitate paper bookkeeping ledgers

Spreadsheet Applications

More than one person can use...at a time

Stored Data

The assessment in a SOAP record in the physician's interpretation of the...

Subjective and Objective findings

The Chief Complaint (CC) is the patient description of the problem or complaint, and it is located in the...

Subjective area of the SOAP note

What are the most powerful computers available?

Supercomputers

Transcriptionist use...to input medical data

Templates

T.I.D. means

Three times a day

A technology being used in medical and other offices for data input is...

Voice-Recognition Technology

Uses radio waves rather than wires or cables, as the medium for transmitting data

Wireless Communications/Connectivity

Used to enter, edit, format , and print documents

Word Processing Program

To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level...

between 2 and 2.5 feet away

File folders may be open on...

one, two, or three sides

...Assigned to limit the number of individual who have access to particular computer files and to help user create a...

password/ audit trail