Which of the following statements is true about a personal health record (PHR)?
A. It must be maintained in paper form.
B. It is maintained by the care provider.
C. It is maintained by the patient (or legal guardian).
D. It is a legal document.
Answer: C
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June is 22 weeks pregnant. This is her third pregnancy. June is seen in the outpatient prenatal clinic complaining of spotting. The spotting started several hours ago and she is concerned about the baby. Her physician asked her to come to the clinic so she could be examined for any potential complications. On physical exam, both June and the fetus are fine, however, the doctor has put June on bed
rest for the next four days to see if the spotting stops. June is to call tomorrow to report on the spotting. She is to return to the clinic immediately if the spotting becomes heavier or more frequent. Dx: Spotting; 22nd week of pregnancy First-listed diagnosis: ________ Second-listed diagnosis: ________ Fill in the blank with correct word.
Computer assisted coding uses software to automatically generate __________ by "reading" transcribed clinical documentation provided by health care practitioners
a. data entry b. insurance claims c. medical codes d. validation/audit reviews