AMCA MAAC key terms

Any individually identifiable health information created, received, or maintained by a covered entity or its business associate. It includes names, dates, record numbers, and any data that could reasonably identify a patient.

The HIPAA rule requiring that only the least amount of protected health information needed to accomplish a task be used, disclosed, or requested. It applies to most routine uses but not to treatment disclosures.

A written document a covered entity must give patients explaining how their health information may be used and disclosed, the patient's rights, and the entity's legal duties. Patients typically acknowledge receipt at check-in.

A patient's signed, specific permission allowing a covered entity to use or disclose protected health information for purposes outside treatment, payment, or operations. It must describe the information, recipient, purpose, and expiration.

The three core activities for which HIPAA permits use and disclosure of protected health information without patient authorization: delivering care, billing for it, and running the practice.

A contract between a covered entity and a vendor that handles protected health information on its behalf. It requires the vendor to safeguard the data and report breaches.

The HIPAA requirement that covered entities notify affected individuals, the Department of Health and Human Services, and sometimes the media after an impermissible disclosure of unsecured protected health information.

The formal process of disclosing a patient's medical records to an authorized person or entity. It requires a valid, signed authorization and careful verification of the requester's identity and legal right to the records.

A patient's right to receive a list of certain disclosures of their protected health information made by a covered entity, typically covering the prior six years. Routine treatment, payment, and operations disclosures are usually excluded.

A documentation format organized around a patient's specific problems, each with subjective findings, objective findings, an assessment, and a plan. It supports structured, consistent clinical note-taking.

A structured progress note with four sections: Subjective (patient's reported symptoms), Objective (exam findings and data), Assessment (clinical impression), and Plan (next steps and treatment).

A systematic review of medical records to verify completeness, accuracy, and compliance with documentation standards. Findings are used to correct errors and improve quality.

An automated, chronological record of who accessed or modified electronic health information and when. It supports security monitoring and investigation of improper access.

The patient's main reason for the visit, recorded in the patient's own words or a brief summary. It directs the focus of the history and examination.

A detailed account of the current problem, including onset, location, duration, character, aggravating and relieving factors, and timing. It is a required element of most documentation.

A series of questions about symptoms across body systems, used to identify problems the patient may not have mentioned. It is documented separately from the physical exam.

A record of the patient's prior illnesses, surgeries, hospitalizations, immunizations, and chronic conditions. It provides context for the current complaint and ongoing care.

The process of comparing a patient's current medication list with newly ordered medications to identify duplications, omissions, or interactions. It is typically done at each transition of care.

Recording the specific substance, the reaction, and the severity of each known allergy, including drug, food, and environmental allergies. It must be verified and updated at each visit.

A structured grid that defines available appointment slots by provider, day, and visit type. It controls capacity and helps match appointment length to the reason for the visit.

A patient who misses a scheduled appointment without canceling in advance. Practices track no-show rates to manage scheduling efficiency and may apply reminder or policy measures.

Intentionally scheduling more patients than available slots to offset expected no-shows or cancellations. It must be balanced against wait times and staff capacity.

A process for contacting patients when a follow-up visit, screening, or preventive service is due. It supports continuity of care and is usually tracked in the practice management system.

A written notice given to a Medicare patient when a service may not be covered, explaining the likely denial and the patient's option to accept financial responsibility.

A statement from an insurer showing services billed, the amount allowed, the amount paid, and the patient's financial responsibility. It is not a bill.

A fixed dollar amount a patient pays at the time of service, as defined by the insurance plan. It is separate from deductible and coinsurance amounts.

The percentage of allowed charges a patient pays after the deductible is met, with the insurer paying the remainder. For example, a 20 percent coinsurance means the patient pays 20 percent.

The amount a patient must pay out of pocket for covered services before the insurance plan begins paying its share. Deductibles typically reset each plan year.

The process that determines which of a patient's insurance plans pays first when more than one plan covers the service. The primary plan pays first and the secondary plan may cover remaining costs.

A standardized code set maintained by the American Medical Association that describes medical, surgical, and diagnostic services. It is used to report procedures for reimbursement.

The code set used to report diagnoses and reasons for visits in the United States. Accurate coding supports medical necessity, reimbursement, and public health reporting.

A category of CPT codes that describes office and hospital visits, selected by documented level of history, examination, and medical decision-making or time.

The determination that a service is reasonable, appropriate, and required for the diagnosis or treatment of a patient's condition. Payers require documentation supporting it before paying a claim.

A payer's refusal to pay a submitted claim, often due to missing information, coding errors, or lack of medical necessity. Denials must be reviewed and may be appealed within deadlines.

A claim submitted with all required information correct and complete, so it can be processed without additional review. Clean claims reduce denials and speed reimbursement.

The process of sorting patients by the urgency of their condition to prioritize care. It determines who is seen first when resources are limited.

Measurements of basic body functions, typically including temperature, pulse, respiration rate, blood pressure, and sometimes oxygen saturation and pain. They help detect changes in patient status.

Emergency chest compressions and rescue breaths used to maintain circulation and breathing when a patient's heart or breathing has stopped. Prompt initiation improves survival.

A portable device that analyzes a heart rhythm and delivers a shock to restore a normal rhythm during sudden cardiac arrest. It provides voice prompts for trained and untrained responders.

The building blocks of medical words: a root carries the core meaning, a suffix modifies it, and a prefix adds location, number, or time. Recognizing these parts lets you decode unfamiliar terms.