EHR Exam 1 Questions & Answers 2023/2024

EHR Exam 1 Questions & Answers 2023/2024 retention period - ANSWER-The amount of time patient records must, by law, be maintained by the medical office. A physical collection of a patients healthcare information - ANSWER-Medical record, patient record, EMR. PTSD-first documented when? - ANSWER-Civil war era. First known as "nervous disease" later known as "shell shock" Now known as PTSD. Items found in patient medical records - ANSWER-Clinical information, administrative information, and legal documents legal documents of the record include - ANSWER-Record release, informed consent documents, HIPAA forms, Advanced directives, Living wills, Insurance authorization forms, and healthcare power of attorney forms Who documents reason for visit - ANSWER-medical assistant patient information form (PHI) - ANSWER-A form used to collect a patient's personal and insurance information, emergency contact. Used for accounting. usually updated at least every 12 months. established patient - ANSWER-a patient who has been seen by a provider in the practice in the same specialty within three years day sheet - ANSWER-A register for all daily business transactions such as patient services , payments and adjustments, also known as a day journal.