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level: Clinical Operations

Questions and Answers List

level questions: Clinical Operations

Question	Answer
a program designed to prompt providers with clinical decisions.	Clinical Decision Support System (CDSS)
Health information that is specific to a patient.	Protected Health Information (PHI)
minor disclosures that may occur during legitimate use of information even when reasonable security measures are in place.	Incidental Disclosures
Protecting private health information by limiting access based on need.	Minimum Necessary Concept
looking at an organization's processes, identifying where and how much data could be accessed inappropriately, and taking steps to prevent it.	Risk Analysis and Management
limiting access to work areas, as well as proper disposal and re-use of electronic media and devices.	Physical Safeguards
password protection, a secure server with dual authentication systems for remote access, and backup systems that maintain an exact copy of each patient record.	Technical Safeguards
Converting email or other information into code that only intended recipients can read.	Encryption
can include having designated employees responsible for security, training, staff education, and having a system for evaluating effectiveness of security measures.	Administrative Safeguards
for security must be in writing and updated whenever there is a change that can affect EHR security. Any time a policy is changed, the old policy must be accessible for review for 6 years.	Policies and Procedures
the main reason for the visit as stated by the patient.	Chief Complaint
a summary of what the patient tells the clinical staff about their history, family history, problems, concerns, symptoms, and goals.	Subjective Elements
anything that can be observed or measured by clinical staff (prior records, vitals signs, tests, imaging results, speech, behavior observations, and physical examination findings.)	Objective Data
Internal policies designed to prevent claim errors, fraud, and abuse.	Compliance Programs
All processes that relate to claims and payment, or other ways of generating revenue.	Revenue Cycle
the ability of different information systems and software applications to communicate and exchange data and use the information exchanged.	Interoperability
is a discipline concerned with the design of tools, machines, and systems that take into account human capabilities, limitations, and characteristics. The goals are to design for safe, comfortable, and effective human use.	Human Factors Engineering (HFE)
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.	Prevent Care Screening
a person or entity that provides services to a covered entity that involves the disclosure of PHI.	Business Associates
the practice of maintaining the security and confidentiality of patient records. It involves both the conversational discretion of health care providers and the security of medical records.	Privacy Rule
to ensure that every covered entity has implemented safeguards to protect the confidentiality, integrity, and availability of electronic protected health information.	Security Rule
is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.	The Joint Commission
the U.S. federal agency that works with state governments to manage the Medicare program, and administer Medicaid and the Children's Health Insurance program.	Center for Medicare and Medicaid (CMS)