CRC Final Exam Study Guide Questions With 100% Correct Answers

CRC Final Exam Study Guide Questions With 100% Correct Answers Health record (Medical Record) - answerWritten or graphic information documenting the facts and events during the rendering of patient care. SOAP notes - answerOffice visit notes organized into four sections: Subjective, Objective, Assessment, Plan EMR - answerAn electronic file wherein patients health information from a single medical provider is stored in a computer system EHR - answerA computerized lifelong healthcare record for and individual that incorporates data from all providers who treat the individual. EHR advantages - answerAccessibility between providers improves quality of care; Cost savings and increased efficiency; Requires no physical storage; Reduced charting errors; Automatic data capture Attending physician - answerHospital staff member who is legally responsible for care and treatment given to a patient Legible documentation requirement - answerInfo in the health record must be easily recognizable by someone outside of the medical practice who is unfamiliar with the handwriting. Internal Audits - answerAudits performed by a staff member of the practice or by a hired consultant to uncover problems in coding and billing compliance so they can be corrected. Prospective Review - answerReview of billing and coding completed BEFORE claims are submitted. Retrospective Review - answerInternal review of billing and coding completed AFTER claims are submitted and after ins co has responded. Compliance Plan - answerA medical practice's written policies for complying with payer and government regulations in order to avoid fraud and abuse. Collections Specialist - answerStaff member trained to work with patients to resolve overdue bills