Health Information & Data Content Flashcards

What does the acronym 'EHR' stand for in the context of health information management?

Answer: Electronic Health Record

EHR stands for Electronic Health Record, a digital version of a patient's paper chart that is real-time and patient-centered.

Which section of the medical record documents a patient's subjective complaints, objective findings, clinical assessment, and treatment plan?

Answer: SOAP note

A SOAP note organizes clinical documentation into Subjective, Objective, Assessment, and Plan sections.

A 'late effect' or 'sequela' in ICD-10-CM coding refers to:

Answer: A residual condition that remains after the acute phase of an illness or injury has resolved

Sequela describes the residual condition or late effect that persists after the acute phase of the original illness or injury is resolved.

Which type of health record release requires a signed patient authorization before disclosure?

Answer: Release to the patient's attorney for litigation

Releasing records to an attorney for litigation requires a signed patient authorization because it is not a routine treatment, payment, or operations purpose.

In CPT coding, what is the significance of a 'semicolon' (;) in a code description?

Answer: The portion before the semicolon is shared by the parent code and all indented codes below it

In CPT, the common descriptor before the semicolon applies to the parent code and all indented child codes that follow.

Which data quality characteristic ensures that health data is recorded at or near the time the care was provided?

Answer: Timeliness

Timeliness means data is recorded promptly after the care event to ensure relevance and reliability.

The 'Minimum Necessary' standard under HIPAA requires covered entities to:

Answer: Limit disclosure of PHI to the minimum amount necessary to accomplish the intended purpose

The Minimum Necessary standard limits PHI disclosures to only what is needed to accomplish the specific purpose of the request.