Download NHA CEHRS Final Exam: Comprehensive Glossary of Key Terms and Concepts and more Exams Management of Health Service in PDF only on Docsity!
NHA CEHRS FINAL EXAM|| 2025 - 2026 ||ACTUAL
230 + EXAM QUESTIONS AND CORRECT
DETAILED RESPONSES WITH RATIONALES
(VERIFIED SOLUTIONS) ALREADY GRADED A+
DICOM (Digital Imaging and Communications in Medicine) - BEST RESPONSE>>>standard and protocol used for transmitting digital radiographic and endoscopic images for clinical use. It is not used to transmit administrative data. CDISC (Clinical Data Interchange Standards Consortium) - BEST RESPONSE>>>an organization that creates standards for health care research and has the goal of promoting systems interoperability to advance medical research. It is not a computer protocol used for transmitting data. (NCPDP) national council for prescription drug programs - BEST RESPONSE>>>an organization that creates standards for transmitting prescription information between pharmacies and providers. abbreviations - BEST RESPONSE>>>American Hospital Association policy states that they should be eliminated from vital parts of the medical record, including final diagnoses and discharge summaries.
advanced directive (living will) - BEST RESPONSE>>>legal document that contains information about the patients treatment choices when they are unable to make healthcare decisions aging report - BEST RESPONSE>>>report that identifies past due patient or insurance account balances and is usually run monthly assignment of benefits - BEST RESPONSE>>>a patient authorization to allow health insurance payment to be made directly to the provider of services authorization - BEST RESPONSE>>>a document that approves disclosure of protected health information unrelated to treatment under the HIPAA privacy rule benchmark - BEST RESPONSE>>>a measure of performance against industry standards business associate - BEST RESPONSE>>>a third party entity that has contact with protected health information to provide services unrelated to treating
covered entity - BEST RESPONSE>>>a medical or health care service, organization, agency, or individual that has protected health information Current Procedural Terminology (CPT) 4th edition - BEST RESPONSE>>>a coding classification system used to report professional services and procedures provided to a patient at ambulatory care centers, medical clinics, and other outpatient care facilities de-identification - BEST RESPONSE>>>the process of removing personal health information accessible to providers and other staff members with login credentials regardless of location electronic health record (EHR) - BEST RESPONSE>>>a record of patient health care information accessible to providers and other staff members with login credentials regardless of location electronic medication administration record (eMAR) - BEST RESPONSE>>>an electronic record containing a patients medication, administration times, and who administered it
encoder - BEST RESPONSE>>>software used to assign diagnosis and procedural codes encounter form - BEST RESPONSE>>>and itemized bill for services that contains diagnosis and procedure codes and is used by administrative staff to complete claims forms; also known as a superbill, fee slip, or charge form encryption - BEST RESPONSE>>>converting email or other information into a code that only intended recipients can read explanation of benefits (EOB) - BEST RESPONSE>>>a statement that shows a patient how services provided were processed by the insurance carrier Health Information Technology for Economic and Clinical Health (HITECH) Act - BEST RESPONSE>>>federal legislation that expands consumer rights and protections outlined by HIPAA and sets standards for quality and use of EHR Health Insurance Portability and Accountability Act (HIPAA) - BEST RESPONSE>>>a federal law that regulates use of patient personal identifiable information
performed at inpatient facilities interoperability - BEST RESPONSE>>>the ability of systems to share and use information laboratory information system (LIS) - BEST RESPONSE>>>a data base or prescribed laboratory test and results transferred from instruments used to analyze the test medical record number (MRN) - BEST RESPONSE>>>a set of numbers used to identify a patient and associated recorded health data minimum necessary concept - BEST RESPONSE>>>protecting private health information by limiting access to information based on minimum need notice of privacy practices (NPP) - BEST RESPONSE>>>a document that is required by law to inform patient how the organization will use their health care information physical safeguards - BEST RESPONSE>>>physical method, policy, or procedures to protect stored data and software from threats, natural and
environmental hazard, and unauthorized invasion physician query - BEST RESPONSE>>>a request that a provider add documentation to an EHR to clarify a diagnosis or procedure that has been performed practice management system (PMS) - BEST RESPONSE>>>a system that stores information on revenue cycle processes, appointments, registration, scheduling, health information management, coding, and billing protected health information (PHI) - BEST RESPONSE>>>health information specific to a patient quality measures - BEST RESPONSE>>>standards or processes implemented to improve clinical quality as defined by clinical professionals and public health organizations redundancy - BEST RESPONSE>>>duplicate copies of data registration form - BEST RESPONSE>>>a form that consist of administrative information about a patient, including personal, financial, and some clinical data
past medical history - BEST RESPONSE>>>The past medical history section contains the objective findings from a patient's previous visit, including operations, injuries, and treatments. superbill - BEST RESPONSE>>>form generated for billing that includes commonly used services and diagnoses. It would not include vital signs. assessment - BEST RESPONSE>>>includes the diagnosis codes determined by the provider. It would not include vital signs. growth chart - BEST RESPONSE>>>A pediatric growth chart is a graphic sheet of the measurements of a child's growth rate. preventive care screen - BEST RESPONSE>>>includes suggestions of preventive care, such as cancer screenings, based on age, sex, and medical history. immunizations screen - BEST RESPONSE>>>includes the patient's immunization records. The preventive care screen includes suggestions of preventive care, such as cancer screenings, based on age, sex, and medical history.
test results screen - BEST RESPONSE>>>includes a list of tests and results. The preventive care screen includes suggestions of preventive care, such as cancer screenings, based on age, sex, and medical history. work-list report - BEST RESPONSE>>>helps coders prioritizes patient accounts for coding from oldest to newest. UB- 04 form - BEST RESPONSE>>>is used for inpatient and facility billing. This form is used to submit the codes for reimbursement after they are captured during the visit. CMS-1500 form - BEST RESPONSE>>>the universal claim form used for outpatient and professional billing. This form is used to submit the codes for reimbursement after they are captured during the visit. progress note template - BEST RESPONSE>>>the location a provider would document a patient's progress and would not be used during a detailed eye examination. specialized template - BEST RESPONSE>>>address the specific documentation
automatic alert message - BEST RESPONSE>>>would send a alert text or page to notify the provider of the change in the patient's laboratory values. entity authentication - BEST RESPONSE>>>method used to verify proof of identify. integrity controls - BEST RESPONSE>>>protocols that verify the data sent is the same as the data received. chief complaint - BEST RESPONSE>>>information about the patient's reason for the visit. It does not contain information about active problems documented on a prior visit. problem list - BEST RESPONSE>>>current list of any of the patient's diagnosed conditions that is maintained from visit to visit. radiology information system (RIS) - BEST RESPONSE>>>database that stores information on radiology ordering, scheduling, appointments, referrals, reporting, and other items used by the radiology professionals to track patient data. RIS does not store imaging pictures.
picture archiving and communication system (PACS) - BEST RESPONSE>>>imaging storage system that enables radiology providers to interpret the results of imaging procedures. Information from PACS integrates into the EHR through observance of interoperability standards, such as the use of HL7. clinical encoder - BEST RESPONSE>>>software that assists with assigning accurate diagnosis and procedure codes for billing purposes. clinical decision support system (CDSS) - BEST RESPONSE>>>A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge- based clinical decisions and integrated with the facility's EHR system to provide statistics and monitoring for a variety of health system functions and to identify areas for process and quality improvement. production by procedure report - BEST RESPONSE>>>indicates the number of total procedures completed within a given timeframe along with the associated revenue generated by each type of procedure. billing/payment status report - BEST RESPONSE>>>lists the financial status of every patient account.
wave scheduling - BEST RESPONSE>>>several patients are scheduled to arrive at the same time, and the number of appointments is determined by the length of the average appointment. cluster scheduling - BEST RESPONSE>>>similar appointment types are scheduled together at specific times. Scheduling well-child visits in the morning and sick child visits in the afternoon is an example of cluster scheduling. modified wave scheduling - BEST RESPONSE>>>several patients are scheduled to arrive at intervals in the first half hour, and then the provider uses the second half hour to conclude visits with all the patients. production by provider report - BEST RESPONSE>>>lists the number of patients seen by each provider and the income received by the organization for their services assignment of benefits - BEST RESPONSE>>>a signed statement that allows the provider's office to receive direct payment for services provided. computer workstation - BEST RESPONSE>>>consists of a computer; an
input device to enter data, such as a keyboard, mouse, or touchscreen; and an output device such as a screen or monitor, which displays the data. advanced beneficiary notice (ABN) - BEST RESPONSE>>>waiver of liability that indicates a service is not covered by Medicare and is the patient's financial responsibility. The EHR specialist should check for an ABN prior to billing a patient. physical examination - BEST RESPONSE>>>documentation of vital signs, including temperature, pulse, respirations, and blood pressure administrative safeguards - BEST RESPONSE>>>covers individual security responsibilities and security and safety training for users and employees. technical safeguards - BEST RESPONSE>>>covers automated processes, such as the encryption and decryption of data. Flow sheet - BEST RESPONSE>>>used to record a patient's vital signs over time, which would include temperature values. concurrent coding - BEST RESPONSE>>>allows coders to see documentation while the patient is still receiving treatment so coding can occur on an ongoing
⦁ Age appropriate immunization status ⦁ Age appropriate feeding/dietary status chief complaint documentation - BEST RESPONSE>>>⦁ Location of pain or symptoms ⦁ Quality (sharp, dull, burning) ⦁ Severity ⦁ Duration ⦁ Timing ⦁ Context (e.g., blood sugar elevations that occur after eating certain foods) ⦁ Modifying factors ⦁ Associated signs and symptoms HIPAA eligibility transaction system (HETS) - BEST RESPONSE>>>Medicare system for verifying coverage of services (eg. skilled nursing facilities and inpatient stays) EHR incentive program requirements - BEST RESPONSE>>>⦁ Use of a certified EHR in a meaningful manner (e-prescribing, computerized provider order entry,
recording demographic information) ⦁ Use of certified EHR technology for the electronic exchange of health information to public health agencies for immunization registries, reportable laboratory results, and syndromic surveillance ⦁ Use of certified EHR technology to submit clinical quality measures (CQM) reports digital dashboards - BEST RESPONSE>>>integrates information from multiple components and tailors the information to individual preferences such as charts or graphs balanced scorecards - BEST RESPONSE>>>compares the actual performance to the actual goal, such as in a bar graph form day sheet report - BEST RESPONSE>>>a report that providers information on practice activities for 24 hours, 3 types: patient/payment/procedure code production by insurance report - BEST RESPONSE>>>the summary of all proceeds received from insurance carriers. The report lists the companies, charges, amounts paid, and adjustments. The report is used to
