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Electronic Health Records (Midterm) > Midterm > Flashcards

Midterm Flashcards

1
Q

Electronic health record?

A
  • Available electronically
  • Recorded electronically by multiple healthcare members
  • Single file that can be accessed
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2
Q

Difference of EMR and EHR?

A

An EMR is available to only 1 facility. EHR available to multiple.

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3
Q

Longitudinal health record contains?

A
  • Documentation from multiple providers
  • Stores patient info as long as received care
  • It’s not static; changing with patient care
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4
Q

EHR does not include what type of info?

A

Security info

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5
Q

What is true about the interoperability?

A

The higher the level the greater the capability of interoperation.

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6
Q

Difference between level 2 and 3 interoperability?

A
  • Level 2 data format is common, level 3 data is shared

- Level 3 is higher level interoperability

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7
Q

Syntactic Interoperability?

A
  • There’s common data between the 2 systems
  • They have a common technical foundation
  • The data cannot be interrupted
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8
Q

What is not true about Interoperability?

A

It is designed specifically for healthcare.

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9
Q

A computer protocol is?

A

A standard method of communication between 2 computers.

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10
Q

What is the ONC role?

A

To improve healthcare and health for all Americans through use of info and technology.

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11
Q

Nationwide Health Information Network (NwHIN)

A

A set of standards, services, and policies that make it possible to securely exchange health info over internet.

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12
Q

HITECH act marks significant achievement for healthcare because:

A
  • Billions of dollars for healthcare info technology
  • Provides incentives for physicians and hospitals
  • Established national health info technology research center
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13
Q

____________ are not eligible providers for medicare.

A

Doctors of Psychiatry

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14
Q

_________________ are not eligible providers for medicaid.

A

Doctors of Optometry.

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15
Q

One way the govt encouraged implementation of EHRs?

A

By reducing reimbursement rates gradually for physicians.

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16
Q

Meaningful use?

A

Set of standards for using EHRs defined by CMS.

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17
Q

What is NOT true about meaningful use?

A

Criteria are to be implemented in all facilities at the same time.

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18
Q

What are the benefits of an EHR?

A
  • Improved documentation
  • Improved access
  • Faster communication
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19
Q

What’s the difference between RHIT and RHIA?

A

RHIA - Bachelors

RHIT - Associates

20
Q

Challenge of EHRs present opportunities in which main areas?

A
  • Privacy and security

- Training

21
Q

What may NOT be considered a healthcare facility according to US National Library of Medicine?

A

Insurance company

22
Q

1 of the greatest accomplishments of the ACS is?

A

-Established the minimum standards for hospitals

23
Q

Media used to store med records over the years?

A
  • Paper
  • Microfilm
  • Optical Scanning
24
Q

A health record includes?

A
  • Past medical condition
  • Present health info
  • Treatments provided
25
Q

What is NOT an example of legal data?

A

Emergency contact info

26
Q

Who primarily uses the core data set developed by the AHIMA?

A

Physician offices

27
Q

Health Record format can:

A

Vary but needs to be consistent.

28
Q

Patients admitted to an acute care setting or long term hospital are?

A

Inpatients

29
Q

What is Source-oriented format (SOR)?

A

Going from one source to another.

30
Q

The Dr. removed liver tissue and sent to the lab for analysis. He completed a:

A

Pathology

31
Q

Consent is signed by the patient, a discharge summary is signed by ___________.

A

The physician

32
Q

A typical document found in an ambulatory care record but NOT in a hospital?

A

-Problem list

33
Q

Referral

A

Document that gives patient permission to be seen by another provider.

34
Q

What is NOT considered general guidelines for documentation?

A

-Ensuring there is no corrected documentation.

35
Q

A wrong entry can be changed by:

A

Writing an addendum documented in an EHR.

36
Q

____________ is NOT an accreditation?

A

American Health Information Management Association (AHIMA)

37
Q

Example of challenges that may be associated with EHRs?

A

-Training users may be difficult

38
Q

Which is NOT true about a well designed EHR?

A

Physicians love it because they no longer have to sign documents.

39
Q

Example of clinical input.

A

Diagnosis code

40
Q

Which is NOT an example of Unstructured data?

A

Gender

41
Q

Searching for and examining data to organize into useful patterns and trends is?

A

Data mining

42
Q

Manual data collection is accomplished by?

A

Staff directly typing it in.

43
Q

Dr. Lee notes patient complains of abdominal pain, vital signs, etc. What document will this info be found?

A

History and physical

44
Q

Physical exam does NOT include?

A

Allergies

45
Q

Patient is complaining of chest pain. What type of info is this?

A

Subjective

46
Q

Nurse orders antibiotics. Which part of history and physical is this documented?

A

Treatment plan

Electronic Health Records (Midterm) (1 decks)

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