Midterm

Question 1

Electronic health record?

Answer 1

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

Question 2

Difference of EMR and EHR?

Answer 2

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

Question 3

Longitudinal health record contains?

Answer 3

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

Question 4

EHR does not include what type of info?

Answer 4

Security info

Question 5

What is true about the interoperability?

Answer 5

The higher the level the greater the capability of interoperation.

Question 6

Difference between level 2 and 3 interoperability?

Answer 6

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

- Level 3 is higher level interoperability

Question 7

Syntactic Interoperability?

Answer 7

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

Question 8

What is not true about Interoperability?

Answer 8

It is designed specifically for healthcare.

Question 9

A computer protocol is?

Answer 9

A standard method of communication between 2 computers.

Question 10

What is the ONC role?

Answer 10

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

Question 11

Nationwide Health Information Network (NwHIN)

Answer 11

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

Question 12

HITECH act marks significant achievement for healthcare because:

Answer 12

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

Question 13

____________ are not eligible providers for medicare.

Answer 13

Doctors of Psychiatry

Question 14

_________________ are not eligible providers for medicaid.

Answer 14

Doctors of Optometry.

Question 15

One way the govt encouraged implementation of EHRs?

Answer 15

By reducing reimbursement rates gradually for physicians.

Question 16

Meaningful use?

Answer 16

Set of standards for using EHRs defined by CMS.

Question 17

What is NOT true about meaningful use?

Answer 17

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

Question 18

What are the benefits of an EHR?

Answer 18

• Improved documentation
• Improved access
• Faster communication

Question 19

What’s the difference between RHIT and RHIA?

Answer 19

RHIA - Bachelors

RHIT - Associates

Question 20

Challenge of EHRs present opportunities in which main areas?

Answer 20

• Privacy and security

- Training

Question 21

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

Answer 21

Insurance company

Question 22

1 of the greatest accomplishments of the ACS is?

Answer 22

-Established the minimum standards for hospitals

Question 23

Media used to store med records over the years?

Answer 23

• Paper
• Microfilm
• Optical Scanning

Question 24

A health record includes?

Answer 24

• Past medical condition
• Present health info
• Treatments provided

Question 25

What is NOT an example of legal data?

Answer 25

Emergency contact info

Question 26

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

Answer 26

Physician offices

Question 27

Health Record format can:

Answer 27

Vary but needs to be consistent.

Question 28

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

Answer 28

Inpatients

Question 29

What is Source-oriented format (SOR)?

Answer 29

Going from one source to another.

Question 30

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

Answer 30

Pathology

Question 31

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

Answer 31

The physician

Question 32

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

Answer 32

-Problem list

Question 33

Referral

Answer 33

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

Question 34

What is NOT considered general guidelines for documentation?

Answer 34

-Ensuring there is no corrected documentation.

Question 35

A wrong entry can be changed by:

Answer 35

Writing an addendum documented in an EHR.

Question 36

____________ is NOT an accreditation?

Answer 36

American Health Information Management Association (AHIMA)

Question 37

Example of challenges that may be associated with EHRs?

Answer 37

-Training users may be difficult

Question 38

Which is NOT true about a well designed EHR?

Answer 38

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

Question 39

Example of clinical input.

Answer 39

Diagnosis code

Question 40

Which is NOT an example of Unstructured data?

Answer 40

Gender

Question 41

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

Answer 41

Data mining

Question 42

Manual data collection is accomplished by?

Answer 42

Staff directly typing it in.

Question 43

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

Answer 43

History and physical

Question 44

Physical exam does NOT include?

Answer 44

Allergies

Question 45

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

Answer 45

Subjective

Question 46

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

Answer 46

Treatment plan