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HCA PT. 1 Exam Questions with correct Answers 2024/2025( A+ GRADED 100% VERIFIED).
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HCA PT. 1 Exam Questions with correct Answers 2024/2025( A+ GRADED 100% VERIFIED).
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HCA PT. 1health record - ANS A health record can be defined as written or graphic information
documenting facts and events during the rendering of patient care. Either paper or electronic
format.
American Recovery and Reinvestment Act of 2009 (ARRA) - ANS encourages implementation
by offering five annual financial incentives for qualifying offices that convert to an electronic
format beginning in 2011 and ending in 2015 or 2016.
Health record content (common) - ANS 1. Patient registration (demographic information)
2. Medication record
3. history and physical exam, notes or report
4. Progress or chart notes
5. Consultation reports
6. imaging and x-ray reports
7. Laboratory reports
8. Immunization record
9. Consent and authorization forms
10. Operative report
11. Pathology report.
In hospital setting would also include
- attending physician's orders
- date of admission
- hospital stay dates
- discharge date
- discharge summary
What types of systems are used in the electronic health record system (EHR) - ANS 1.
problem-oriented record (POR system)
2. source-oriented record (SOR system or integrated system)
Problem-Oriented Record System (POR) - ANS consists of: flow sheets, charts, or graphs, that
allow aphysician to quickly locate information and compare eaulation
Source-Oriented Record system (SOR) - ANS documents are arranged according to sections
(e.g., H&P section, progress notes, lab tests, radiology reports, or surgical operations) SOR
system filed in reverse chronological order. More difficult to locate data due to scattering
throughout
,Electronic Health Record System - ANS collection of medical information about the past,
present and future of a patient that resides in a centralized electronic system.
Difference between an EHR and an EMR - ANS An EMR is an individual physician's EMR for
the patient, including medical history, allergies, and appointment information.
An EHR is all patient medical information from many information systems, including all
components of the EMR.
Advantages of EHR - ANS Advantages of EHR1. no physical space required
2. abstracting data is eliminated except when free-form documentation such as narrative notes,
dictations, and natural language processing is used.
3. free-text approach, encourages use of abbreviations or fewer spelled out words may result in
scant or undecipherable documents.
4. Electronic systems have built in security safeguards to protect against improper disclosure,
unauthorized access, or unintended alteration of information for both the data and the system.
5. ARRA requires covered entities to notify individuals if their protected health information is
accessed or disclosed in an unauthorized manner.
SNOMED-CT - ANS Systematized Nomenclature of Medicine for Clinical Terminology. Medical
terminology classification system that codes text data in an EHR system will assist in
standardizing clinical medical terminology
Medicare Modernization Act - ANS created the Commission on Systemic Interoperability to
develop a strategy to make healthcare information available at all times to patients and
physicians. Goal by 2014.
Electronic medical report - ANS part of the health record that is used to complete the insurance
claim form.
permanent legal document that formally states outcomes of the patients' examination or
treatment in letter or report form.
Insurance claim - ANS - DOS, date of service
- POS, place of service
- Dx, diagnosis
- Procedures
- codes are used for interpretation by the insurance company when processing a claim
documentaries - ANS all individuals providing healthcare services that chronologically record
pertinent facts and observations about a patient's health.
documentation - ANS charting, may be electronically handwritten, dictated and transcribed or
downloaded from a (PDA) personal digital assistant or smartphone
, speech recognition system - ANS computerized voice recognition system which makes it
possible for computer to respond to spoken words
medical editor - ANS correctionist, proofreads and edits the computer-generated documents
attending physician - ANS refers to the hospital staff member who is legally responsible for the
care and treatment given to a patient
consulting physician - ANS provider whose opinion or advice regarding evaluatio or
management of a specific problem is requested by another physician
non-physician practitioner (NPP) - ANS nurse practitioner, clinical nurse specialist, licensed
social worker, nurse midwife, physical therapist, speech therapist, audiologist, or physician
assistant who furnishes a consultation or treats a patient for a specific medical problem,
pursuant to state law, and who use the results of a diagnostic test in the management of the
patient's specific medical problem
ordering physician - ANS individual in the hospital directing the selection, preparation, or
administration of tests, medication, or treatment
primary care physician (PCP) - ANS oversees the care of the patients in a managed health
care plan and refers patients to see specialists for services as needed
referring physician - ANS provider who sends the patient for tests or treatment
resident physician - ANS physician who has finished medical school and is performing one or
more years of training in a specialty area on the job at a hospital (medical center). Residents
perform the elements required for an evaluation and management (E/M service in the presence
of or, jointly with, the teaching physician, and residents document the service.
teaching physician - ANS doctor who has responsibilities for training and supervising medical
students, interns, or residents and who takes them to the bedsides of patients in a teaching
hospital to review course and treatment. Teaching physicians must document that they
supervised and were physically present at the time during key portions of the service provided
to the patient when performed by a resident.
Treating or performing physician - ANS provider who renders a service to a patient. In the
Medicare program, the definition of a treating physician is a physician who furnishes a
consultation or treats a beneficiary for a specific medical problem and who uses the results of a
diagnostic test in the management of the beneficiary's specific medical problem.
Five reasons for legible documentation - ANS :If handwritten, entries in the patient record must
be legible.
a. avoids denied or delayed payments by insurance carriers
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