61 EHR final

Question 1

PHI

Answer 1

Protected Health Information [patient’s personally identifiable health info protected by HIPAA Privacy Rule]

Question 2

PHR

Answer 2

Personal Health Record [electronic health record owned, maintained by patient]

Question 3

EHR

Answer 3

Electronic Health Record [portions of patient’s med records stored in comp sys]

Question 4

remote access

Answer 4

The ability to access the EHR from outside the medical facility network by using a direct dial connection or a secure internet connection.

Question 5

forces driving EHR

Answer 5

Health Safety (reduce errors), Health Costs (e.g. life-threatening situations due to adverse drug reactions), Changing Society (increased patient mobility, specialization, internet)

Question 6

Org certifies EHR sys’s

Answer 6

CCHIT: Certification Commission for Healthcare Information Technology

Question 7

Sx

Answer 7

Symptoms [Subjective]

Question 8

Hx

Answer 8

History [Subjective]

Question 9

Px

Answer 9

Physical Exam [Objective]

Question 10

Tx

Answer 10

Tests (PERFORMED) [Objective]

Question 11

Dx

Answer 11

Diagnosis [Assessment]

Question 12

Rx

Answer 12

Therapy, plan and tests (ORDERED) [Plan]

Question 13

OTC

Answer 13

over the counter

Question 14

explain HL7

Answer 14

Health Level Seven, leading messaging standard used to exchange clinical and administrative data b/w diff hc comp sys

Question 15

what’s H&P

Answer 15

History & Physical

Question 16

Name 3 body sys

Answer 16

GI (gastrointestinal), MS (musculoskeletal), GI (genitourinary)

Question 17

what’s IOM

Answer 17

Institute of Medicine (of the National Academies. nonprofit org created to provide unbiased, evidence-based, authoritative info and advice on health and science policy.

Question 18

what’s SNOMED-CT

Answer 18

Systemized Nomenclature of Medicine Clinical Terms. (merger of coding sys’s SNOMED and Read codes; recommended to become core terminology for codified EHR in US)

Question 19

CCC

Answer 19

Clinical Care Classification system [used by nurses to codify documentation of pat care in any setting. Evolution of HHCC (home health care classification) nursing codes]

Question 20

CPOE

Answer 20

Computerized Physician/Provider Order Entry (process of e entry of med practitioner instructions for the treatment of pats [particularly hospitalized] under his/her care. orders communicated over comp net to the med staff / depts responsible for fulfilling the order. form of pat mgmt sw)

Question 21

DUR

Answer 21

Drug Utilization Review. (process of comparing a prescription drug to a pat’s hx & recent meds for contraindications, OD, UD, allergic rxns, drug-to-drug & drug/food interactions)

Question 22

explain ICD-9-CM coding sys

Answer 22

Int’l Classification of Diseases, 9th Rev, CMods. Sys of standardized codes to classify mortality & morbidity. Currently published in 3 vols. 1st 2 provide listing & index of diagnosis codes. 3rd lists codes for hosp procedures

Question 23

explain ICD-9-CM use in outpatient settings

Answer 23

only for diagnoses

Question 24

when will ICD-10 be introduced to the US

Answer 24

10/1/14

Question 25

pending order

Answer 25

Lab tst / diagnostic proc that’s been ordered but for which no results have been received

Question 26

problem list

Answer 26

Acute conditions for which the pat was recently seen and chronic conditions (hi bp, diab) which are monitored nearly every visit, and can affect decisions about meds & treatments for even unrelated diseases

Question 27

What’s HPI

Answer 27

History of Present Illness. (chrono desc of the dev’t of pat’s PI from 1st sign/symp to present)

Question 28

what's BMI

Answer 28

Body Mass Index. (number that shows body weight adjusted for height)

Question 29

group that developed preventative screening

Answer 29

CDC: Centers for Disease Control and Prevention

Question 30

Age for 1st dose of Hep B

Answer 30

At birth

Question 31

What’s ROS

Answer 31

Review of Systems. (way of organizing an exam by body systems from head down)

Question 32

Standard code sets for OP

Answer 32

ICD-9-CM, CPT-4 (Current Procedural Terminology, 4th Ed), HCPCS (Hc Common Proc Coding Sys)

Question 33

Passed by Congress in ’96

Answer 33

HIPAA: Health Insurance Portability and Accountability Act

Question 34

Came into law in ’03

Answer 34

Privacy Rule (HIPAA) (fed privacy protections for individually identifiable health info)

Question 35

Privacy Rule applies to

Answer 35

Electronic, written, oral (all forms of pat’s PHI)

Question 36

Security Rule applies to

Answer 36

Only PHI that is in electronic form

Question 37

3 security safeguards

Answer 37

Administrative (security training requirements), Physical (retaining off-site comp backups, Technical (ID & passwords)

Question 38

Hc settings that use DRG

Answer 38

Inpatient care for Medicare patients

Question 39

What’re E&M codes

Answer 39

Eval & Mgmt codes, subset of CPT-4 codes used to bill for nearly every kind of pat encounter

Question 40

what codes for procedures in OP settings

Answer 40

CPT-4

Question 41

4 levels of E&M codes

Answer 41

Least complicated exam (lvl 1) to most complex exam (lvl 4)

Question 42

security standards

Answer 42

Administrative (admin. fxs implemented to meet sec stans), Physical (mechs required to protect e sys, equip, data from threats, env’t hazards, unauth intrusion), Technical (automated processes used to protect data and control access to data) safeguards

Question 43

HCPCS

Answer 43

Common Proc Coding Sys. (extended set of billing codes for reporting med services, procs, and treats incl codes not listed in CPT-4)