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23 Cards in this Set

  • Front
  • Back

Major safeguard to help secure access to the EHR information is

Each user should be given PASSWORDS that are confidential to protect health information.

E-Prescribing

A way of routing prescriptions directly to a pharmacy (it's a function within the EHR system, not a safeguard)

Hacking

An activity that can give users illegal access to a system and is a federal crime

Special note documentation

Possibly phone calls, messages, legal correspondence, surgical notes, etc.

SOAP

S:Subjective = statements about symptoms, social history, how the patient feels


O:Objective = actual data from examination, x-rays, laboratory reports, etc.


A: Assessment = diagnosis from the physicians analysis of the subjective and objective


P:Plan = the treatment plan and course of follow up action

CHEDDAR

C:Chief Complain


H:History of presence illness


E:Examination


D: Details


D:Drugs and dosage


A:Assessment


R:Return Visit info/ referral

Search engines and operating system

Search engines are used to look up information on the internet (Google, Yahoo, Bing) operating system is the program that actually runs the computer

Scanner, printer & copy machine, mouse

Scanner will capture images and convert them to digital forms that can be stored or otherwise maniplulated on a computer.


Printer and copy machine produce a hard copy of a document


Mouse is used to move the cursor and navigate through computer screen

In-network and Non-Network

Prenegotiated rates are the amounts paid by the patient for any health care services provided by the In-Network provider. More out of pocket expenses can be expected if non network providers have not contracted with the insurance company for a fee schedule.

For-Profit and Not for profit

Most insurance companies operates as for profits (employers sponsored or individual plans) as opposed to not for profit (SCHIP, TRICARE, state and federal problem)

Managed care

Used in reference to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care. It includes incentives for physicians and patients to select less costly forms of care. There is a review of medical necessity for some services. This results in determination to provide the best care at the least cost to the insurer by requiring pre-authorization and or precertification

Rider

A provision on an insurance policy that can be purchased separately from a basic policy that provides additional benefits at additional cost but can also limit coverage.

Referral

Occurs when the insureds primary care physician determines that the patient needs to see a specialist or requires a procedure that they can not perform

Deductible

The amount the patient owes for covered health care service before the insurance plan begins to pay

Precertification

Authorization by an insurance company before a specific medical procedure is done

Exposure control plan

An OSHA (blood borne pathogens standard) that must meet certain criteria and must be reviewed and updated at least yearly and be readily available to all medical staff

Drug enforcement administration (DEA)

Tasked with combatting drug smuggling and use of illegal drugs within the United States and has sole responsibility for coordinating and pursuing US drug investigations abroad. DEA registration certificates must be renewed every 3 years.

FDA food and drug administration

Responsible for protecting and promoting public health through regulating and supervision of prescription and over the counter pharmaceutical drugs, vaccines, biopharmaceutical, blood transfusion, medical devices

DHHS

Goal to protect the health of all Americans and providing essential human services

Needlestick safety and prevention act

In 2000, the act was signed into law to help eliminate or minimize exposure risk due to accidental needlesticks

Clinical laboratory improvement Amendments (CLIA)

Laws put in place to ensure quality aussurance standards for medical laboratories

HIPAA (Health insurance portablility and accountability act)

A set of regulations put in place to ensure confidentiality of health insurance also making it easier for a person to keep their health insurance if they lose or change jobs

Narcotics license

A physician must have one to give them the legal right to dispense controlled substances.