EHR Electronic Health Record

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President Bush recommended the use of Health Information Technology H I T. And set a goal for all Americans to be using Electronic Health Records EHR by what year?
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2004
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HIPAA act of 1996
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was designed to protect a patients private health information, ensure healthcare coverage for workers who lost or changed their jobs, and help uncover fraud or abuse in healthcare.
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The Institute of Medicine
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Suggests EHR have 8 core elements. Health Information & Data Elements, Results Management, Order Management, Decision Support, Electronic communications & Connectivity, Patient Support, Administrative Process,Reporting & Population Management
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Electronic Medical Records \”EMR\”
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Computerized records of one physician’s encounter with a patient over time.
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Electronic Health Record \”EHR\”
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a computerized lifelong health care record for an individual that incorporates data from providers who treat the individual.
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Personal Health Record \”PHR\”
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Maintained and owned by the patient. Information sheet that contain the individual’s medical history, including diagnoses, symptoms, and medications
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Acute Care
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Most often refers to a Hospital, treats patients with urgent problems.
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Ambulatory Care
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Another term for outpatient care
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Advantages of Electronic Health Records
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* Safety * Quality of Care * Efficiency * Cost Reduction
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Total Conversion
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may be costly; allows all patient data to be converted at once while office still sees patients
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Incremental Conversion
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gradual change to EHR, lower cost, smoother transition and less impact on office, however paper is still used and not all patient data available
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Hybrid Conversion
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uses combination of paper and electronic forms of data
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Clinical Vocabularies
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Set of common definitions for medical terms they ease communication by decreasing ambiguity
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SNOMED-CT \”Systematized Nomenclature of Medicine Clinical Terms\”
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Clinical Vocabulary disigned to encompass all terms used in medicine
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LOINC \”logical observation identifier names and codes\”
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Terms and codes used for electronic exchange of lab results and clinical observations.
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UMLS \”Unified Medical Language System.\”
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Thesaurus database of medical terms.
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ICD-9 & ICD-10
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international classification of diseases developed by the World Health Orgnanization \”W H O\”
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CPT
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current procedural terminology developed and maintained by the AMA
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Code Range for Evaluation & Management \”E&M\”
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99201-99499
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Code Range for Anestesia
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00100-01999
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Code Range for Surgery
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10021-69990
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Code Range for Pathology & Lab
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80047-89356
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Code Range for Medicine
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90281-99607
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HCPCS
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Healthcare common procedural coding system.
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HCPCS Level II
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Contains codes for products, supplies and certain services not included in the CPT manual. These codes are maintained by the Centers for Medicare and Medicaid Services. CMS
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Standard: Health Level Seven \”HL7\” 2.3+
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Scheduling, medical record and image management, patient administration, observation reporting, financial management, public health notification, and patient care.
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National Council for Prescription Drug Programs \”NCPDP\” SCRIPT
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Retail pharmacy transactions
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Institute of Electrical and Electronics Engineers, Inc. \”IEEE\”
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Device/device transactions
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Digital Imaging and Communicatons in Medicine \”DICOM\”
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Image information to workstations
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HL7 version 2.4+
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Demographics
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Systematized Nonmenclature of Medicine Clinical Terms \”SNOMED CT\”
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Lab Result contents
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HL& Version 2.x+
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Units of measure
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CVX
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vaccines administered
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MVX
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manufacturers of vaccines
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CDC
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Centers for Disease Control and Prevention
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NIP
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National Immunization Program
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Active Ingredient
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FDA established names & \”Unique Ingredient Identifier Codes\” UNII
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Manufactured Dosage
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FDA/CDER data standards manual
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Drug Product
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FDA National Drug Codes \”NDC\”
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Medication Package
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FDA Standards manual
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Label Section Headers
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LOINC Clinical Structured Product Labeling \”SPL\”
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HL7 \”Health Level Seven International\”
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Is a standard for exchanging information between medical applications. This standard defines a format for the transmission of health-related information.
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Drug Classifications
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Department of Veteran Affairs National Drug File Reference Terminology \”NDF-RT\”
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Clinical Drug
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National Library of Medicine’s Rx Norm
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Verbal Communication
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Oral communication; Speech. The process of sending and receiving messages with words, including writing and sign language.
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Nonverbal Communication
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Use of eye contact , Body Language, facial expression, or symbolic expressions to communicate a message
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Respect
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courteous regard for people’s feelings
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Step 1 of patient flow
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appointment scheduling Information collecting
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Step 2 of patient flow
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Patient Check-in payment collection
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Step 3 of patient flow
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Rooming Measurements Vitals Patient Examination and documentation
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Step 4 of patient flow
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Patient Checkout
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Step 5 of patient flow
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Coding and Billing Review test results
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Vital signs
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measurements of physiological functioning, specifically body temperature, pulse, respirations, and blood pressure; may include pain level and pulse oximetry
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Chief Complaint
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main reason for the visit to the medical office.
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Progress Notes
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Record of the continuing progress and treatment of a patient.
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Past Medical History \”PMH\”
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A listing of any illnesses the patient may have had in the past; includes treatments and procedures performed.
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Family History
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review of medical events in the patients family
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Social History
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a detailing of the patient’s lifestyle and personal habits
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Allergies
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A list of the patients allergies as well as their reactions to each one
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Medication List
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Information regarding the dosage and frequency of the patients medication
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History of present illness \”HPI\”
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a description of the course of the present illness,including how and when the problem began, up to the present time
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Review of Systems \”ROS\”
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systematic head to toe review \”questions about\” all major body systems
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Diagnosis and Assessment
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The physicians conclusion regarding the cause of the patients problem
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Clinical Tools
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EHR’S allow the ability to access research, detail national treatment,eaiser to manage patients w/chronic deseases, allow doctors to Order tests, medications, Send prescriptions to pharmacy, checks medication contradictions & errors.
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E-Prescribing
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Transmission of a prescription via electronic means. EHR programs will send alerts for potential prescription problems.
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The Primary Benefits of Hospital EHR
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* Unlimited access to patients information *Decreased waiting time for medication delivery as well as test results *Increased efficiency and accuracy in overall patient care
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Computerized Physician Order Entry \”CPOE\”
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is an application used by physicians and other health care providers to enter patient care information
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The five rights of eMars
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1. The right patient 2. The right medication 3. The right dose 4. The right time 5. The right route \”oral or intravenous\”
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Adverse drug effects \”ADE\”
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Side effects or complications from medications
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Benefits of the Personal Health Record \”PHR\”
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The elimination of errors made by patients filling out forms, records can be accessed from any location. Ensures the safety of health records located in healthcare facilities in the event of a natural disaster.
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Computer Based -Stand Alone
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*transferred to a portable memory device to be accessed from a different location *access to their PHR using a software program that has been downloaded or installed onto their computer
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Internet Based-tethered
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accesses through outside organization such as insurance company limited editing capability. ownership of helath care record is maintained by the organization that provides access to the user.
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Internet Based-Untethered
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Individuals are granted access to their personal health record through a web based application. Upon the creation of a user name and password the user is able to create and update information as needed.
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Internet Based-networked and interoperable
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Networked personal health record allows transfer of personal health record to providers such as insurance companies and pharmacies. Continually updated does not ensure privacy and security
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HIPAA Title I
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Insurance reform–The purpose is to provide continuous insurance coverage for workers and their insured dependents when they change or lose their job.
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HIPAA Title II
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Provides rights for the transfer of electronic health care data. Adminstration and Simplification Standards \”Title II\” put privacy and security mechanisms in place to ensure personal health info is kept confidential.
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Health Plan
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individual or group plan that provides or pays for medical care
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Providers
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anyone who provides medically related services that can be reimbursed. A provider may be a physician, dentist, clinic, hospital, pharmacy, lab
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Clearinghouses
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Companies that process health information and execute electronic transactions
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Designated Record Set \”DRS\”
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any item, collection, or grouping of information that includes protected health information and is maintained by a covered entity
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Electronic Protected Health Information \”ePHI\”
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Protected health information that is created, received, maintained or transmitted in electronic form
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Notice of Privacy Practices \”NPP\”
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document that described practices regarding the use and disclosure of protected health information
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Protected Health Information \”PHI\”
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Individually identifiable health information that is transmitted or maintained by electronic media.
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Treatment, Payment and Operations \”TPO\”
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Conditions under which protected health information can be released without consent from the patient
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The following is considered \”PHI\”
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*Name * Address *Names of relitives and employees *Social Security Number *Phone & fax numbers *Email addresses *Health Plan ID number *Account number ETC…..
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Rights of Individuals
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Access copy of PHI, request amendment of record, request restrictions on uses and disclosures of PHI, and file a complaint about a violation with the Office of Civil Rights
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National Council for Prescription Drug Program
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A standardized system used to transfer prescription information
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Deep
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Away from the surface
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Proximal
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close to the origin of the body part or the point of attachment of a limb to the body trunk
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Distal
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farther from the origin of a body part or the point of attachment of a limb to the body trunk
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Inferior
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below another structure
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Superior
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above another structure
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Medial
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Toward the midline of the body.
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Lateral
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pertaining to the side
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Supine
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lying on the back
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Prone
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lying on the belly
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2014
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In what year must everyone be using the EHR system
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Level II HCPCS
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product supplies services not included in CPT manual
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Order Sets
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pre-defined groupings of standard orders for a condition, disease or procedure
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The center for Medicare and Medicaid Services \”CMS\”
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Maintain the HCPCS codes
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Decision support tools
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makes the last clinical information available to provide at the point-of-care
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Medical Records
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An important business document , a medical record is used to support treatment decisions, document services provided & could be used in a court of law for evidence purposes,
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Plan & Treatment
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The physicians recommended plan of action to cure or manage patients condition

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