Med Claims Chapter 2
Study online at https://quizlet.com/_ifaium
1. What is the primary role of medical They work with clinical and demographic data to as-
insurance specialists? sess the medical necessity of claims.
2. What is the importance of patient It helps physicians provide the right level of care and
clinical information? assess claims for payment.
3. What has replaced the manage- Healthcare records are moving to a digital platform.
ment of paper files in healthcare?
4. What is a medical record? A file containing documentation of a patient's medical
history and related information.
5. What does malpractice refer to in a The failure to use professional skill when providing
medical context? medical services, resulting in injury or harm.
6. What is meant by documentation in The recording of a patient's health status in a medical
medical records? record.
7. What are medical standards of State-specified performance measures for the deliv-
care? ery of healthcare.
8. What is the significance of a pa- It provides continuity and communication among
tient's medical record in a physician healthcare professionals involved in the patient's care.
practice?
9. How do medical records assist in re- They provide data and insights into patient conditions
search and education? and treatment outcomes.
10. What are the differences between EHRs are comprehensive records from all sources
Electronic Health Records (EHRs) treating an individual, while EMRs are records from
and Electronic Medical Records one physician's encounters with a patient.
(EMRs)?
11.
, Med Claims Chapter 2
Study online at https://quizlet.com/_ifaium
What are Personal Health Records Private, secure electronic files controlled by patients
(PHRs)? that contain their health information.
12. What is the advantage of using EHRs provide immediate access to health information
EHRs over paper records? and reduce the time needed to find vital patient data.
13. What is computerized physician or- A system that allows physicians to enter orders for
der entry management? prescriptions and tests electronically.
14. What is clinical decision support in Access to the latest medical research to assist in med-
EHR systems? ical decision-making.
15. What are automated alerts and re- To ensure patients are scheduled for screenings and
minders in EHR systems used for? to identify patient safety issues.
16. How do EHR systems facilitate com- They provide secure and easily accessible communi-
munication between physicians cation channels.
and staff?
17. What is the relationship be- If a service is not documented, it cannot be billed.
tween documentation and billing in
healthcare?
18. What defines medically necessary Services that are reasonable and essential for diagno-
services? sis or treatment consistent with accepted standards of
care.
19. What is a hybrid record system? A system that uses both electronic and paper records
in physician practices.
20. Why is complete and comprehen- To show that physicians have followed the medical
sive documentation important? standards of care applicable in their state.
21.
, Med Claims Chapter 2
Study online at https://quizlet.com/_ifaium
What does the term 'medical pro- The responsibility of licensed healthcare professionals
fessional liability' refer to? to provide a certain level of care.
22. What role do electronic health They decrease errors that result from illegible chart
records play in reducing medical er- notes by allowing electronic entry.
rors?
23. What is the purpose of patient med- They defend against accusations of improper treat-
ical records as legal documents? ment by clearly documenting services provided.
24. What is the rationale behind treat- It establishes the medical necessity of treatments
ment decisions documented in based on the patient's condition.
medical records?
25. How do EHRs support patient edu- They provide information on health topics and instruc-
cation? tions for medical tests.
26. What is the significance of e-signa- It verifies the identity of the signer for entries made in
ture technology in EHRs? the medical record.
27. What types of data are included in Current medications, health insurance information,
a patient's personal health record allergies, medical test results, and family medical his-
(PHR)? tory.
28. What is the role of medical records They provide a comprehensive view of a patient's
in ensuring continuity of care? health history for all treating providers.
29. What is an encounter in a medical A visit between a patient and a medical professional
context? for evaluation and management.
30. What does E/M stand for in medical Evaluation and Management.
documentation?
31.
, Med Claims Chapter 2
Study online at https://quizlet.com/_ifaium
What information should be doc- Patient's name, encounter date and reason, history
umented during a patient en- and physical examination, review of tests, diagnosis,
counter? plan of care, and provider's signature.
32. What biographical information Full name, date of birth, address, marital status, phone
must be included in a patient's numbers, and employer information.
medical record?
33. What types of communications with Letters, phone calls, faxes, emails, and the patient's
the patient must be recorded? responses.
34. What is the SOAP format in medical Subjective, Objective, Assessment, Plan.
documentation?
35. What are the four types of informa- Chief complaint, H&P examination, diagnosis, and
tion documented in a complete his- treatment plan.
tory and physical (H&P)?
36. What is informed consent in a med- The process by which a patient authorizes medical
ical context? treatment after discussing risks and recommenda-
tions with a physician.
37. What should progress reports doc- Patient's progress, comparisons of objective data with
ument? patient statements, goals, and current condition.
38. What is included in discharge sum- Final diagnosis, comparisons of objective data, goals
maries? achieved, reason for discharge, current condition, and
discharge instructions.
39. What types of documentation are Procedure reports, laboratory test reports, radiology
required for procedural services? reports, and specific purpose forms.
40.
Study online at https://quizlet.com/_ifaium
1. What is the primary role of medical They work with clinical and demographic data to as-
insurance specialists? sess the medical necessity of claims.
2. What is the importance of patient It helps physicians provide the right level of care and
clinical information? assess claims for payment.
3. What has replaced the manage- Healthcare records are moving to a digital platform.
ment of paper files in healthcare?
4. What is a medical record? A file containing documentation of a patient's medical
history and related information.
5. What does malpractice refer to in a The failure to use professional skill when providing
medical context? medical services, resulting in injury or harm.
6. What is meant by documentation in The recording of a patient's health status in a medical
medical records? record.
7. What are medical standards of State-specified performance measures for the deliv-
care? ery of healthcare.
8. What is the significance of a pa- It provides continuity and communication among
tient's medical record in a physician healthcare professionals involved in the patient's care.
practice?
9. How do medical records assist in re- They provide data and insights into patient conditions
search and education? and treatment outcomes.
10. What are the differences between EHRs are comprehensive records from all sources
Electronic Health Records (EHRs) treating an individual, while EMRs are records from
and Electronic Medical Records one physician's encounters with a patient.
(EMRs)?
11.
, Med Claims Chapter 2
Study online at https://quizlet.com/_ifaium
What are Personal Health Records Private, secure electronic files controlled by patients
(PHRs)? that contain their health information.
12. What is the advantage of using EHRs provide immediate access to health information
EHRs over paper records? and reduce the time needed to find vital patient data.
13. What is computerized physician or- A system that allows physicians to enter orders for
der entry management? prescriptions and tests electronically.
14. What is clinical decision support in Access to the latest medical research to assist in med-
EHR systems? ical decision-making.
15. What are automated alerts and re- To ensure patients are scheduled for screenings and
minders in EHR systems used for? to identify patient safety issues.
16. How do EHR systems facilitate com- They provide secure and easily accessible communi-
munication between physicians cation channels.
and staff?
17. What is the relationship be- If a service is not documented, it cannot be billed.
tween documentation and billing in
healthcare?
18. What defines medically necessary Services that are reasonable and essential for diagno-
services? sis or treatment consistent with accepted standards of
care.
19. What is a hybrid record system? A system that uses both electronic and paper records
in physician practices.
20. Why is complete and comprehen- To show that physicians have followed the medical
sive documentation important? standards of care applicable in their state.
21.
, Med Claims Chapter 2
Study online at https://quizlet.com/_ifaium
What does the term 'medical pro- The responsibility of licensed healthcare professionals
fessional liability' refer to? to provide a certain level of care.
22. What role do electronic health They decrease errors that result from illegible chart
records play in reducing medical er- notes by allowing electronic entry.
rors?
23. What is the purpose of patient med- They defend against accusations of improper treat-
ical records as legal documents? ment by clearly documenting services provided.
24. What is the rationale behind treat- It establishes the medical necessity of treatments
ment decisions documented in based on the patient's condition.
medical records?
25. How do EHRs support patient edu- They provide information on health topics and instruc-
cation? tions for medical tests.
26. What is the significance of e-signa- It verifies the identity of the signer for entries made in
ture technology in EHRs? the medical record.
27. What types of data are included in Current medications, health insurance information,
a patient's personal health record allergies, medical test results, and family medical his-
(PHR)? tory.
28. What is the role of medical records They provide a comprehensive view of a patient's
in ensuring continuity of care? health history for all treating providers.
29. What is an encounter in a medical A visit between a patient and a medical professional
context? for evaluation and management.
30. What does E/M stand for in medical Evaluation and Management.
documentation?
31.
, Med Claims Chapter 2
Study online at https://quizlet.com/_ifaium
What information should be doc- Patient's name, encounter date and reason, history
umented during a patient en- and physical examination, review of tests, diagnosis,
counter? plan of care, and provider's signature.
32. What biographical information Full name, date of birth, address, marital status, phone
must be included in a patient's numbers, and employer information.
medical record?
33. What types of communications with Letters, phone calls, faxes, emails, and the patient's
the patient must be recorded? responses.
34. What is the SOAP format in medical Subjective, Objective, Assessment, Plan.
documentation?
35. What are the four types of informa- Chief complaint, H&P examination, diagnosis, and
tion documented in a complete his- treatment plan.
tory and physical (H&P)?
36. What is informed consent in a med- The process by which a patient authorizes medical
ical context? treatment after discussing risks and recommenda-
tions with a physician.
37. What should progress reports doc- Patient's progress, comparisons of objective data with
ument? patient statements, goals, and current condition.
38. What is included in discharge sum- Final diagnosis, comparisons of objective data, goals
maries? achieved, reason for discharge, current condition, and
discharge instructions.
39. What types of documentation are Procedure reports, laboratory test reports, radiology
required for procedural services? reports, and specific purpose forms.
40.
