ch 4 medical documet Word Scramble

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Question	Answer
an individual physician record of the patients care	EMR
all of the patients records,from many different information systems and providers	EHR
the greatest advantage of an EHR system is the improvement of quality of care and patient safety through the ________ of medical records between providers and other health care organizations.	accessibility
providers who are not participating in the E- prescribing incentive plan in 2014 will have medical claimsprocessed with a ____ percent adjustment/reduction in their payments	2.0
stage 2 of the meaningful use incentive program will focus on _________ , which will expand the criteria in areas of disease management, clinical decision support, medication management, transition in care, quality measurement, and research.	advance clinical process
list three of the various types of health record systems that can be used in a medical practice	problem oriented record system (POR), source oriented record system (SOR), integrated record system
written or graphic info about patient care is termed a	health record
what is the CMS definition of legible documentation?	the data must be easily recognizable by someone outside of the medical practice who is unfamiliar with the handwriting
performance of services or procedures consistent with the diagnosis, donr with standards of good medical practice and a properlevel of care given in the appropriate setting is known as	medical necessity
medicare administrative contractors have ______ to access a medical practice without an appointment or search warrent to conduct a review of documentation, audits, and evaluations.	walk in rights
a list of all staff members names, job titles, signatures, and their initials is known as	signature log
for electronic health records, how should an insurance billing specialist correct an error on a patients record?	note section as error with date, time, enter correct info w/ notation of when and why the physician changed entry.
fro paper based records, how whould an error be corrected on a patients record?	mark w/ one line through, write correct info, date and initial it.
if a medical practice is audited by medicare officials and intentional miscoding is discoverd, _____ and may belevied and providers may be _____.	fines, excluded
when each entry in the medical record is worded similar to the previous entries this is considered	cloned documentation
an electronic medical report is a	permanent legal document, part of the health record
the key to substaining procedure and diagnostic code selections for proper reimbursment is	supporting documentation in the electronic health record
the chronological recording of pertinent facts and observations about the patient's health is known as	documentation
reasons for documentation are	defense of a professional liability claim, insurance carriers require accurate documentation that supports procedure and diagnostic codes
the SOAP in patient medical record charting may be defined as	subjective, objective, assessment, plan
when a patient fails to return for needed treatment, documentation should be made	in the patients medical record, in the appointment book, on the financial record or ledger card
how should an entry in a patients electronic medical record be corrected?

Created by: eg6791