CCA Exam Domain 5 (Already Passed!)

Encoder correct answers Computer software that helps the coding professional to assign codes. This software now includes assistance with other coding systems Computer Assisted Coding correct answers Utilizes natural language processing (NLP) and algorithmic software to electronically analyze entire medical charts to pre-code with both CPT procedure and ICD10 diagnostic nomenclatures Natural language processing correct answers Considered a special form of data entry, it is the capability of a computer to apply very sophisticated mathematical and probabilistic formulas to narrative text and convert them to structured data. Although text processing is becoming more feasible, the technology has a long way to go before it can be used routinely Grouper correct answers Coders enter the codes that have been selected into this computer program. It then assigns the patient's case to the correct group based on the ICD-10-CM and/or CPT/HCPCS codes Digital dictation system correct answers Today, hospitals may use speech recognition systems where dictation automatically converts to text. Dictators themselves can make any necessary corrections as they are dictating or transcriptionists can make corrections. Such systems permit clinicians to continue using paper-based processes for their day-to-day clinical functions but enhance the ability to gain access to information, which has been a major problem with paper-based records Electronic signature authentication correct answers A system that requires the author of a document to sign onto a patient record using a user ID and password, reviews the document to be signed, and indicates approval Single sign-on correct answers A type of technology that allows a user access to all disparate applications through one authentication procedure, thus reducing the number and variety of passwords a user must remember and enforcing and centralizing access control Clinical data repository correct answers A central database that focuses on clinical information Electronic health record correct answers Information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization Electronic document management system correct answers A storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents that can be stored electronically on optical disks Picture archiving and communications system correct answers An integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images)