healthcare documentation quiz Flashcards
(33 cards)
1
Q
CHI
A
computerized health information
2
Q
EMR
A
electronic medical record
3
Q
EHR
A
electronic health record
4
Q
EPR
A
electronic pt record
5
Q
CPR
A
computerized pt record
6
Q
PHR
A
personal health records
7
Q
PHI
A
personal health information
8
Q
PMR
A
pt medical record
9
Q
PMRI
A
pt medical information
10
Q
e-sign
A
digital signature
11
Q
EP
A
eligible professional
12
Q
EOE
A
electronic order entry
13
Q
CPG
A
clinical practice guidelines
14
Q
CPM
A
clinical performance measures
15
Q
CI
A
clinical indications
16
Q
CPOE
A
computerized physician order entry
17
Q
POC
A
point of care
18
Q
formulary
A
standard pharmacy of facility
19
Q
EBM
A
evidenced based practice
20
Q
SNOMED
A
global language of healthcare
21
Q
WOW
A
workstation on wheels
22
Q
COW
A
computer on wheels
23
Q
EHT
A
electronic health technology
24
Q
role of EHT
A
- improve the quality of health care
- prevent medical errors
- reduce health care costs
- increase administrative efficiencies
- decrease paperwork
- expand access to affordable healthcare
- maintain client privacy laws
25
EH
eligible hospitals
26
CAHs
critical access hospitals
27
centers of medicare & medicaid services (CMS)
- incentive programs provide incentive payments to EP, EH, and CAHs
- as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology
28
"meaningful use"
-using certified EHR technology in ways that can positively impact pt care
29
examples of meaningful use
- CPOE for medication orders
- record VS
- medication reconciliation
- advance directives
- recoding smoking status
- active medication list
30
healthcare outcomes
- improve quality, safety, efficiency, and reduce health disparities
- engage pts and families in their healthcare
- improve care coordination
- ensure adequate privacy and security protections for PHI
- improve individual and community health
31
EHR/EMR include this important info
- immunizations
- allergies
- demographics
- advanced directives
- appts
- insurance/fin info
- MD orders
- H&P
- nurse charting
- current meds
- lab/dx test restults
- adjunct care
- consults
32
levels of automation
- administrative (pt info, address, contacts, insurance, billing, etc)
- clinical date repository (basic clinical documentation)
- barcode medication
- ancillary orders/reports: lab, dx, radiology
- healthcare personnel communications
- pt portals
- MD access from mobile devices
- able to predict and address epidemic issues for any area using historical data and other factors
33
clinical vocabulaires
- use of a standardized vocab
- ex: leukopenia vs low white blood count
- without this, an automated system cannot recognize terms as being equivalent when queried
