Health record (Medical Record)
Written or graphic information documenting the facts and events during the rendering of patient care.
SOAP notes
Office visit notes organized into four sections: Subjective, Objective, Assessment, Plan
EMR
An electronic file wherein patients health in...
CRC final exam study guide 2023
Health record (Medical Record) - correct answer Written or graphic information documenting the facts and events during the rendering of patient care.
SOAP notes - correct answer Office visit notes organized into four sections: Subjective, Objective, Assessment, Plan
EMR - correct answer An electronic file wherein patients health information from a single medical provider is stored in a computer system
EHR - correct answer A computerized lifelong healthcare record for and individual that incorporates data from all providers who treat the individual.
EHR advantages - correct answer Accessibility between providers improves quality of care; Cost savings and increased efficiency; Requires no physical storage; Reduced charting errors; Automatic data capture
Attending physician - correct answer Hospital staff member who is legally responsible for care and treatment given to a patient
Legible documentation requirement - correct answer Info in the health record must be easily recognizable by someone outside of the medical practice who is unfamiliar with the handwriting.
Internal Audits - correct answer Audits performed by a staff member of the practice or by a hired consultant to uncover problems in coding and billing compliance so they can be corrected.
Prospective Review - correct answer Review of billing and coding completed BEFORE claims are submitted. Retrospective Review - correct answer Internal review of billing and coding completed AFTER claims are submitted and after ins co has responded.
Compliance Plan - correct answer A medical practice's written policies for complying with payer and government regulations in order to avoid fraud and abuse.
Collections Specialist - correct answer Staff member trained to work with patients to resolve overdue bills.
Financial policy - correct answer The medical practice's clear explanation of billing procedures and financial rules, which should be signed by all patients.
Physician fee schedule - correct answer Service fees must be the same for all patients and and a list of common services, descriptions, and fees must be available to all patients.
Missed appointment fees - correct answer Typically $35-50, due from the patient.
Cash patients - correct answer A discount may be offered to all patients who pay cash up front (self pays).
Financial hardship discounts - correct answer Hardship must be proven and documented, and discounts must be equally available to all patients based on financial need.
Professional courtesy - correct answer The questionable practice of offering reduced or free services to medical professionals or their families.
The Federal Truth in Lending Act - correct answer When interest or finance charges are added to
a balance, or if more than 4 installments are scheduled to pay off a balance, this law requires disclosure forms to be signed informing the patient of the APR, Finance Charge amount, total financed amount, total of payments, and payment schedule.
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