The _____ is a description of what the physician thinks is wrong with the patient: the diagnosis or possible (provisional) diagnoses.
Answer: Assessment
HIS 124
- Components of record retention are: _________
- ______ is what happens to the patient data after the patient is discharged.
- An ________ contains: data and time, list of the activities, the computer in which the activity took place, the user who performed the activity, and a description of the activity itself.
- The correction of errors is an important consideration in patient record keeping because nothing that is recorded should be ________
- The process of determining the cause of an error is often referred to as a ________.
- A ______ might be programmed to print out a list of entries that the compute recognizes as problematic.
- _____ are developed and implemented to ensure that errors in data are discovered.
- One way to prevent invalid data entries is with the use of _____ on a printed form of computer screen.
- ____ are designed to ensure that data errors do not occur in the first place. the best example of a preventive control is a compute validity check.
- One way that data can be protected so that they are accurate, valid, timely, and complete is through the development and implementation of _______
- ___ refers to the collection or recording of data in their entirety.
- A history and physical (H&P) must be completed within ______ of admission or before a surgical procedure.
- The process of recording data into an information system is called ______
- _____ ensures its usefulness. the term validity pertains to the data's conformity with an expected range of values. a computer can be instructed to check specific fields for validity and alert the user to a potential data collection error.
- One consideration that is more important in computer data entry than in paper-record data collection is the _____
- Computerized data capture facilitates the improvement of ________
- Effective training can reduce potential _____ .
- The _____ acts as a review board regarding HIPAA.
- In addition, policies should be developed in compliance with HIPAA that address the following:
- Specific risk areas identified by OIG include:
- Seven Basic Components of a Compliance Plan is
- The _____ prohibit the submission of claims for designated services or referral of patients if the referring physician has a "financial relationship" with the entity that provides the services.
- Federal False Claims Act addresses presenting a claim for an item or service based on a code known to result in greater payment or submitting a claim for services _____.
- ___ occurs when a health care organization practices behavior that is not indicative of sound medical or fiscal activity.
- ___ can occur when deception is used. Individuals who knowingly, willfully and intentionally submit false information to benefit themselves of others commit fraud.