EHR Go 2: Activity on Health Info Terminology (Associate AK1008)Latest Update with complete solution

1. If you have questions about this activity, please contact your instructor for assistance. 2. You will review the chart of Liu Huang to complete this activity. Your instructor has provided you with a link to the Health Information Terminology (AS) activity. Click on 2: Launch EHR to review the patient chart and begin this activity. 3. Refer to the patient chart and any suggested resources to complete this activity. 4. Document your answers directly on this activity document as you complete the activity. When you are finished, you will save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS). Glossary Abstracting: The process of extracting information from a document to create a brief summary of a patient’s illness, treatment and outcome. Addendum: Note that is added (and attached to) to a completed note after it has been finalized (signed by the author). Authorization: The granting of permission to disclose confidential information. As defined in terms of the HIPAA privacy rule, an individual's written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment or health care operations. (45 C.F.R. § 164.508) Care plan: A standardized written plan for the patient’s care for the health care team to follow. Centers for Medicare & Medicaid Services (CMS): The federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare, Medicaid, Children’s Health Insurance Program, and the Health Insurance Marketplace. (CMS) Clinical data: Captured during the process of diagnosis and treatment, supports direct patient care and is used for health care reimbursement, planning and research purposes. (Abdelhak) Coded data: Controlled data entered into specific fields in the EHR which enable the retrieval, or data mining, of the entered information. Examples of coded data include ICD diagnostic codes, CPT procedural codes and health factors. Current Procedural Terminology (CPT): A coding system used to provide uniform language that accurately describes medical, surgical and diagnostic services. Data mining: Aggregating and reporting of data from coded fields within the EHR.◻ EHR Go Knowledge Activity: Health Information Terminology (Associate) AK1008.4 Archetype Innovations LmLesCsag© es.2do0w2nl2 oaded_by2 Diagnosis: The name for the health problem that you have. Often called a “medical problem” or just simply, “problem.” Diagnosis code: A code describing the principal diagnosis, additional conditions that coexisted at the time of admission, or developed subsequently, and which had an effect on the treatment received or the length of stay. Sometimes referred to as the ICD-10 code. Diagnosis Related Groups (DRG): A classification system that groups patients according to diagnosis, type of treatment, age and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. (CMS) Electronic Health Record (EHR): Longitudinal patient records that are maintained electronically in a manner that is accessible to caregiver, the patient and others who need access to specific information or to aggregate information to prevent illness and improve future treatment. Electronic Medical Record (EMR): Electronic patient records that are developed by individual health care providers/organizations. EMRs are composed of whole files as opposed to individual data elements. The data from the EMR are the source of data for the electronic health record. (Abdelhak) Encoder: Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system.