61 EHR final Flashcards
PHI
Protected Health Information [patient’s personally identifiable health info protected by HIPAA Privacy Rule]
PHR
Personal Health Record [electronic health record owned, maintained by patient]
EHR
Electronic Health Record [portions of patient’s med records stored in comp sys]
remote access
The ability to access the EHR from outside the medical facility network by using a direct dial connection or a secure internet connection.
forces driving EHR
Health Safety (reduce errors), Health Costs (e.g. life-threatening situations due to adverse drug reactions), Changing Society (increased patient mobility, specialization, internet)
Org certifies EHR sys’s
CCHIT: Certification Commission for Healthcare Information Technology
Sx
Symptoms [Subjective]
Hx
History [Subjective]
Px
Physical Exam [Objective]
Tx
Tests (PERFORMED) [Objective]
Dx
Diagnosis [Assessment]
Rx
Therapy, plan and tests (ORDERED) [Plan]
OTC
over the counter
explain HL7
Health Level Seven, leading messaging standard used to exchange clinical and administrative data b/w diff hc comp sys
what’s H&P
History & Physical
Name 3 body sys
GI (gastrointestinal), MS (musculoskeletal), GI (genitourinary)
what’s IOM
Institute of Medicine (of the National Academies. nonprofit org created to provide unbiased, evidence-based, authoritative info and advice on health and science policy.
what’s SNOMED-CT
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)
CCC
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]
CPOE
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)
DUR
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)
explain ICD-9-CM coding sys
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
explain ICD-9-CM use in outpatient settings
only for diagnoses
when will ICD-10 be introduced to the US
10/1/14
pending order
Lab tst / diagnostic proc that’s been ordered but for which no results have been received
problem list
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
What’s HPI
History of Present Illness. (chrono desc of the dev’t of pat’s PI from 1st sign/symp to present)
what’s BMI
Body Mass Index. (number that shows body weight adjusted for height)
group that developed preventative screening
CDC: Centers for Disease Control and Prevention
Age for 1st dose of Hep B
At birth
What’s ROS
Review of Systems. (way of organizing an exam by body systems from head down)
Standard code sets for OP
ICD-9-CM, CPT-4 (Current Procedural Terminology, 4th Ed), HCPCS (Hc Common Proc Coding Sys)
Passed by Congress in ’96
HIPAA: Health Insurance Portability and Accountability Act
Came into law in ’03
Privacy Rule (HIPAA) (fed privacy protections for individually identifiable health info)
Privacy Rule applies to
Electronic, written, oral (all forms of pat’s PHI)
Security Rule applies to
Only PHI that is in electronic form
3 security safeguards
Administrative (security training requirements), Physical (retaining off-site comp backups, Technical (ID & passwords)
Hc settings that use DRG
Inpatient care for Medicare patients
What’re E&M codes
Eval & Mgmt codes, subset of CPT-4 codes used to bill for nearly every kind of pat encounter
what codes for procedures in OP settings
CPT-4
4 levels of E&M codes
Least complicated exam (lvl 1) to most complex exam (lvl 4)
security standards
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
HCPCS
Common Proc Coding Sys. (extended set of billing codes for reporting med services, procs, and treats incl codes not listed in CPT-4)
