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
