EHR study guide Questions and answers
Active patient - One who saw the physician in the last 3 years ICD-10-PCS - The format consists of 7 digit codes with the letters a-h, j-n, p-z;replaces vol 3 of the ICD-9-CM Standards - Set of commonly agreed-on specifications Unified medical language system (UMLS) - Reference database of medical vocabularies Clinical templates - Structured progress notes that document patient encounters in an EHR Electronic health record - Computerized lifelong health care record with data from all sources Factors in medical errors - Poor handwriting; mislabled lab specimens, misfiled records Health information Technology (HIT) - Use of technology to manage patient health care information Interoperable - System that can exchange information and use the information in a meaningful way Network - Equipment that enables computers to exchange information electronically Personal health records (PHR) - Individuals comprehensive record of health information; the individual manages the informationElectronic medical record (EMR) - Computerized record of one physician's encounters with a patient over time Providers who do not adopt EHR system by 2014 - Will be subject to financial penalties Business associate - Entity that works under a contract for a covered entity and is therefore subject to the covered entities HIPAA policy and procedures
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