Foundations and communication
- EHR shares across organizations; EMR stays in one practice
- TJC 'Do Not Use': write 'unit', not 'U'
- Open-ended questions, active listening, qualified interpreters, escalate when needed
Law and compliance
- PHI includes identifiers like email and phone; share the minimum necessary
- Mandatory reports: child abuse, certain diseases, gunshot wounds
- Fraud is intentional; abuse is improper practice; SDS for chemicals
Scheduling and encounter
- Wave, modified wave, time-specified, double, open, block scheduling
- Two identifiers prevent duplicate records; document no-shows
- Birthday rule; copay = fixed, coinsurance = %; ABN for possible Medicare non-coverage
Billing and administration
- Revenue cycle starts at registration; clearinghouses scrub claims
- CMS-1500 for professional claims; UB-04 for institutional
- Terminal-digit filing; reconcile petty cash; downtime procedures when the EHR is down
Test yourself on CMAA
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