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level: Nonclinical Operations

Questions and Answers List

level questions: Nonclinical Operations

Question	Answer
an independent, not-for-profit group that certifies electronic health records and networks for health information exchange.	Certification Commission for Healthcare Information Technology (CCHIT)
organization of American physicians, the objective of which is to promote the science and art of medicine and the betterment of public health.	American Medical Association (AMA)
HIPAA-mandated notice that health care providers must give to patients and research subjects that describes how a healthcare provider may use and disclose their protected health information, and informs them of their legal rights regarding PHI.	Notice of Privacy Practices (NPP)
digital records of health information including past medical history, vital signs, progress notes, diagnoses, medications, immunization dates, allergies, lab data and imaging reports. They can also contain other relevant information, such as insurance information, demographic data, and even data imported from personal wellness devices.	Electronic Health Records (EHR)
The number used by the hospital as a systematic documentation of a patient.	Medical Records Number (MRN)
A document that is required by law to inform a patient how the organization will use their health care information.	Notice of Privacy Practices (NPP)
Use of a computer system to enter and process prescriptions and treatments at the point of care.	Computerized Provider Order Entry (CPOE)
An electronic record containing a patient's prescribed medications administration times, and who administered it.	Electronic Medication Administration Record (eMAR)
documentation of an individual's health information that is tracked in both physical and electronic formats.	Hybrid Health Record (HHR)
an encrypted connection over the Internet from a device to a network. The encrypted connection helps ensure that sensitive data is safely transmitted. It prevents unauthorized people from eavesdropping on the traffic and allows the user to conduct work remotely.	Virtual Private Network (VPN)
healthcare software that manages the day-to-day operations of a clinic, such as appointment scheduling, billing and other administrative tasks.	Practice Management System (PMS)
a sub-system of the hospital information system, which is designed to assist pharmacists in safely managing the medication process.	Pharmacy Information System (PIS)
a healthcare software solution that processes, stores, and manages patient data related to laboratory processes and testing.	Laboratory Information System (LIS)
a healthcare database system that keeps track of patient data and image files typically generated in the course of diagnosis and treatment by a radiology medical professional.	Radiology Information System (RIS)
medical imaging technology used primarily in healthcare organizations to securely store and digitally transmit electronic images and clinically-relevant reports.	Picture Archiving and Communication System (PACS)
a policy-neutral access-control mechanism defined around roles and privileges. The components of RBAC such as role-permissions, user-role and role-relationships make it simple to perform user assignments.	Role-Based Access Control (RBAC)
the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care.	Health Information Management (HIM)
a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.	Current Procedural Terminology (CPT)
a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.	International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
codes that are used by providers to bill services based on assessment findings documented in the visit. History • Examination • Medical Determination • Counselling • Coordination Of Care • Nature of Presenting Problem • Time	Evaluation & Management (E&M)
federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. was enacted on August 21, 1996,	Health Insurance Portability and Accountability Act (HIPAA)
encouraged healthcare providers to adopt electronic health records and improved privacy and security protections for healthcare data. This was achieved through financial incentives for adopting EHRs and increased penalties for violations of the HIPAA Privacy and Security Rules.	Health Information Technology for Economic and Clinical Health Act (HITECH)
nicknamed the Recovery Act, was a stimulus package enacted by the 111th U.S. Congress and signed into law by President Barack Obama in February 2009.	American Recovery and Reinvestment Act (ARRA)
health information in any form, including physical records, electronic records, or spoken information. Includes health records, health histories, lab test results, and medical bills.	Protected Health Information (PHI)
a set of international standards used to transfer and share data between various healthcare providers. More specifically, HL7 helps bridge the gap between health IT applications and makes sharing healthcare data easier and more efficient when compared to older methods.	Health Level Seven (HL7)
It is used to share summary information about the patient within the broader context of the personal health record.	Continuity of Care Document (CCD)
is a standard for the creation of electronic summaries of patient health. Its aim is to improve the quality of health care and to reduce medical errors by making current information readily available to physicians.	Continuity of Care Record (CCR)
the ability of different information systems and software applications to communicate and exchange data and use the information exchanged.	Interoperability
a document that a patient can use to reveal important medical information about them. Information that patients must provide in the registration form includes the patient contact information, payment guarantees, and information about the person responsible for payment.	Registration Form
The person who accepts financial responsibility to pay the patient's bill in the case the patient could not.	Guarantor
A legal document that contains information about a patient's treatment choices when they are unable to make health care decisions.	Advance Directives
A patient's authorization to allow health insurance payment to be made directly to the provider of service.	Assignment of Benefits
Information recorded by providers and sometimes the patient during an encounter. This includes financial information entered during scheduling and patient registration to enable reimbursement for services.	Internal Data
Information like digital images and laboratory results often starts outside the office where the patient record lives. Directing information into the patient's electronic record helps create a complete record of the patient.	External Data
Technology that are frequently used in the field like Bar Code Scanners, Cameras, Printers, Signature pads, Fax machines. Usability : The ease with which a person can interact with hardware and software to provide safe, efficient, quality care.	Peripheral Devices