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stuff ni jas > his unit 6 3rd shift > Flashcards

his unit 6 3rd shift Flashcards

1
Q

Collection of computer-stored images of traditional health record documents

A

AHR Automated Health Records

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2
Q

How are AHRs stored/ collected?

A

Scanned into a computer
Stored on optical disks

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3
Q

Contains all personal health information belonging to an individual

A

EHR

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4
Q

Collection of health information for one patient linked by a patient identifier

A

CPR Computer-based Patient Record

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5
Q

What can be included in a CPR?

A

Medication orders
Integrated data on a patient’s registration
Admission and financial details
Recording information from nurses, laboratory, radiology, and
pharmacy

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6
Q

T or F: EHR extends beyond acute inpatient situations

A

T

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7
Q

EHR is entered and accessed electronically by healthcare
providers over ______

A

the person’s lifetime

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8
Q

Developed within a medical practice or health center

A

EMR

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9
Q

Describe automated systems based on document imaging or systems

A

EMR

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10
Q

What does a EMR include?

A

Include patient identification details, medications and prescription generation, laboratory results, and healthcare information recorded by the doctor

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11
Q

The EHR should reflect the ______ of an individual across his or her
lifetime including data from multiple providers from a variety of healthcare settings

A

entire health history

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12
Q

Share information with other health care providers and organizations

A

EHR

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13
Q

EMR enables clinicians to?

A

Track data over time
Easily identify who are due for screenings or checkups
Check their patients
Monitor and improve overall quality of care within the practice

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14
Q

Focus on the total health of the patient

A

EHR

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15
Q

Going beyond standard clinical data collected

A

EHR

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16
Q

Contains medical and treatment history of patients in one practice or organization

A

EMR

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17
Q

Can be gathered, managed, consulted by clinicians and staff in one healthcare organization

A

EMR

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18
Q

Conforms to interoperability standards that can be drawn from multiple sources while being shared, managed, and controlled by the individual

A

PHR

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19
Q

Conforms to nationally recognized interoperability standards
Can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization

A

EHR

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20
Q

What is the major issue that should be address before moving forward?

A

unique patient identification

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21
Q

What is the backbone of an
effective and efficient health record system, whether manual or electronic?

A

Accurate patient identification

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22
Q

Other possible issues of EHR?

A

Clinical data entry issues and lack of standard terminology

Resistance to computer technology and lack of computer literacy

Strong resistance to change by many healthcare providers

High cost of computers and computer systems and funding limitations

Concern by providers as to whether information will be available on request

Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information

Quality of electronic healthcare information and accuracy of data entries

Lack of staff with adequate knowledge of disease classification systems

Manpower issues– lack of staff with adequate skills

Environmental issues

Involvement of clinicians and hospital administrators

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23
Q

What safeguards need to be addressed?

A

Efficient back-up system available
Contingency plans for disaster recovery
Securing workstations and password requirement
Access control to authorized persons only
Audit controls

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24
Q

Staff may be available, but their skills may not be adequate
There is a need for a well-trained workforce

A

Manpower issues– lack of staff with adequate skills

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25
Retention schedules Concerned with how information is to be retrieved
Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information
26
Need to compare the current system costs plus perceived costs for the new EHR system
High cost of computers and computer systems
27
Need to adopt a standard, comprehensive vocabulary and develop a data dictionary
Clinical data entry issues and lack of standard terminology
28
Some prefer to write by hand Some are still not proficient in using computers
Resistance to computer technology and lack of computer literacy
29
The change to entering patients’ health record data via a computer or other electronic device may be difficult. Requires intensive training of healthcare practitioners
Strong resistance to change by many healthcare providers
30
Information should always be readily available can be accessed more efficiently
Concern by providers as to whether information will be available on request
31
What are qualities of quality data?
Accuracy and validity of the original source data Reliability Completeness Legibility Currency and timeliness Accessibility
32
Limited coding training programs Selected people who do not have a medical background
Lack of staff with adequate knowledge of disease classification systems
33
Thorough understanding of clinical data Their specifications and input Willingness to collaborate and share data
Involvement of clinicians and hospital administrators
34
Electrical wiring and supply of electricity Amount and quality of space needed for computers and other equipment
Environmental Issues
35
Core functions of an EHR system?
Health information and data Results management Order entry and support Decision support
36
Other functions of an EHR system?
Electronic communication and connectivity Patient support Administrative processes Reporting and population health management
37
Benefits of using EHR technology?
1. Improve health care quality, safety, and efficiency and reduce health disparities 2. Engage patients and families in their health care 3. Improve care coordination 4. Improve population and public health 5. Ensure adequate privacy and security of personal health information
38
What is a patient portal?
Secure website through which patients can electronically access their medical records
39
Patient portals enables users to?
- Complete forms online ̶ Schedule appointments ̶ Communicate with providers ̶ Request refills on prescriptions ̶ Review test results ̶ Pay bills
40
Factors that increase EHR adoption?
* Improve patient safety * Reduce medical errors * Reduce duplicate services * Improve organizational efficiency * Optimize reimbursement * Complete locally and regionally
41
Barriers to Adoption?
Financial Organizational / Behavioral Technical
42
Use and acceptable of changes in workflow
Organizational / Behavioral
43
Lack of capital or resources needed to develop, acquire, implement, and support a healthcare information system
Financial
44
Work and technology needed to build system interfaces
Technical
45
According to AHIMA (2016) what is a personal health record?
tool to collect, track, and share past and current information about your health or the health of someone in your care effective tool enabling patients to be active members of their own health care teams
46
T or F: PHR is managed by your healthcare provider
F is it not
47
T or F: PHR does not constitute a legal document of care
T
48
Should PHR contain all pertinent health care information?
YES
49
Patient Record Content has?
Identification Screen Problem List Medical Record History and Physical Progress Notes Consultation Note or Report Physician's Orders Imaging and X-ray Reports Laboratory Reports Consent and Authorization Forms Operative Report Pathology Report Discharge Summary
50
Contain results of tests conducted on body fluids, cells, and tissues
Laboratory Reports
51
Who in the lab documents any findings and treatment plans based on lab results?
Physicians
52
Who documents lab results into the patient record?
Lab personnel
53
T or F: Lab Reports must be present during treatment
T
54
Documented in a timely manner
Imaging and X-ray Reports
55
Responsibilities of the radiologist?
Interpret images Document interpretations or findings
56
Identifies significant illness and operations
Problem List
57
Used as clinical and administrative document
Identification Screen
58
How is the problem list maintained over time?
By attending or primary care physician, or health care providers involved
59
Made by physicians, nurses, therapists, social workers, and other staff members Reflect patient’s response to treatment; observations and plans for continued treatment
Progress Notes
60
What is the format for Progress Notes?
SOAP Subjective findings Objective findings Assessment Plan
61
Practitioner who provides treatment must obtain ______
informed consent
62
What needs the consent as alegal document?
STAR Surgery Treatment Admission Release of information
63
Describes any surgery performed Lists the names of surgeons and assistants
Operative Report
64
In a Operative Report, who documents the information?
Surgeons
65
Discharge Summary summarizes?
- Reason for admission ̶ Significant findings from tests ̶ Procedures performed ̶ Therapies provided ̶ Responses to treatments ̶ Condition at discharge ̶ Instructions for medications, activity, diet and follow-up care
66
Discharge summary documented by?
Attending physician
67
Records opinions about the patient’s condition Made by another health care provider at the request of the attending physician
Consultation Note or Report
68
Directions, instructions, or prescriptions
Physician’s Orders
69
Lists medicines prescribed and administered, medication allergies
Medical Record AKA Medication Administration Record (MAR)
70
Who are responsible for documenting and maintaining information?
Nursing personnel
71
Information originates at the time of registration or admission?
Name, address and telephone number Insurance carrier Policy number Diagnoses and disposition at discharge
72
Identifies significant illness and operations
Problem List
73
History component describes?
- Any major illnesses and surgeries the patient had ̶ Family history of disease ̶ Patient health habits ̶ Current medications
74
What the physician found after the hands-on patient examination
Physical component
75
Both history and physical components?
Document the initial patient assessment and provide basis for diagnosis and treatment
76
History is provided by who and documented by who?
̶ Information is provided by the patient ̶ Documented by physician or other care provider
77
May come from physicians and others inside or outside the organization
Consultation Note or Report
78
Physician's orders are given to other members of the health care team regarding the patient’s?
- Medications ̶ Tests ̶ Diets ̶ Treatments, and others

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