Chapter 5

Question 1

Hardware

Answer 1

physical equipment or machinery that is used by a system. In broad definition, it is the cpu, storage devices, input and output devices, and networking equipment. It is the parts of the computer you can touch.

Question 2

CPU

Answer 2

Central Processing Unit

Question 3

Input Devices

Answer 3

Allows users to input information into the computer system

Question 4

Output Devices

Answer 4

Allow users to print or display information produced by a computer system

Question 5

Storage Devices (memory devices)

Answer 5

hold data during processing or for later retrieval and use.

Question 6

Networking Equipment

Answer 6

Includes the wires, modem, routers, and cables to connect the system

Question 7

Operating Software

Answer 7

computer programs that control the hardware and interface with the application software

Question 8

Application Software

Answer 8

consists of computer programs that allow the uses to perform a particular task or function

Question 9

technologically advanced environment

Answer 9

consumes now communicate with providers using mobile health applications and smartphones, thus requiring the healthcare industry to determine how this technology can be used in light of the health information security regulations

Question 10

computerized medical record

Answer 10

1970-1980, term for the early medical record automation efforts that focused on the development of alerts, medication administration records, provider orders, communications, and notes.

Question 11

IOM

Answer 11

Institute of Medicine

Question 12

Longitudinal Patient Record

Answer 12

Contains records from different episodes of care, providers, and facilities that are linked to form a view of a patient health care encounters

Question 13

CPR

Answer 13

Computer Based Patient Record

Question 14

Computer Based Patient Record

Answer 14

multidisciplinary and multienterprise, has the ability to link patient information at different locations according to a unique patient identifier

Question 15

According to the OIM’s 1991 report, electronic record should support the following:

Answer 15

Physician access to patient information, new and past test results in multiple care settings; computerized order entry; computerized decision support systems to prevent adverse drug interactions and improve compliance with best practices; secure electronic communication among providers and patients; patient access to records, disease management tools, and health information resources; computerized administration processes such as scheduling systems, standards based electronic data storage; reporting for patient saferty and disease surveillance efforts

Question 16

Document Imaging / Optical Disc Imaging

Answer 16

provided an alternative to traditional microfilm or remote storage systems as patient records were converted to an electronic image and saved on servers or optical disks

Question 17

Scanner

Answer 17

A scanner is used to capture paper record images onto electronic storage media. Capturing images electronically allows rapid, automated retrieval of records.

Question 18

Prior to scanning a paper record is prepped by:

Answer 18

Removing all staples, paper clips, fasteners; ensuring that patients name and medical record is on all pages and both sides if double sided; repairing any pages that have tears.

Question 19

Indexed

Answer 19

means it is identified according to a unique identification number, which is commonly that patient’s medical record number

Question 20

Bar Codes

Answer 20

Machine generated identification codes that can be used on paper documents

Question 21

Bar Code Reader /Bar Code Scanner

Answer 21

reads the bar code and identifies the document as belonging to a specific patient.

Question 22

Clinical Data Repository

Answer 22

the merging of data from different data systems into one centralized data base.

Question 23

EMR

Answer 23

Electronic Medical Record

Question 24

Electronic Medical Record

Answer 24

Used in the late 1990s to describe systems that were based on imaging and the merging of data from various stand alone systems.

Question 25

Computerized Patient Records

Answer 25

Electronic Medical Record

Question 26

Electronic Medical Record

Answer 26

Computerized Patient Records

Question 27

Health Level 7 (HL&)

Answer 27

A standards-development organization that develops EHR standards under the direction of the US Department of Health and Human Services

Question 28

National Alliance for Health Information Technology

Answer 28

NAHIT

Question 29

NAHIT

Answer 29

National Alliance for Health Information Technology

Question 30

National Alliance for Health Information Technology (NAHIT)

Answer 30

Promoted IT initiatives, consisted of health care providers, payers, and other industry organizations that were stakeholders in the development of IT systems in health care. Accomplished many initiatives that had impact on the advancement of IT in health care in the United States.

Question 31

Electronic Medical Record (Per NAHIT)

Answer 31

An electronic record of health related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization

Question 32

Electronic Health Record (Per NAHIT)

Answer 32

An electronic record of health related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization

Question 33

the difference between electronic medical record and electronic health record

Answer 33

the electronic record incompasses the transmission of health information that is standardized and shared between health care organizations

Question 34

Health Information Exchange (HIE)

Answer 34

Describes the transmission of standardized health information between health care professionals to other professionals and patients

Question 35

Personal Health Record (PHR)

Answer 35

An electronic or paper medical record maintained and updated by an individual for his or her own personal use

Question 36

www.myPHR.com

Answer 36

to learn more about personal health records

Question 37

Electronic Health Record Systems

Answer 37

Combinations of various systems that integrate medical documentation needs into an electronic format. During their careers, health information administrators may work with numerous facilities to implement electronic health record systems in a variety of types of health care organizations

Question 38

Hybrid Records

Answer 38

Part paper, part electronic records

Question 39

Hybrid records

Answer 39

One of the most important issues is when managing a hybrid record is the facility’s definition of its legal records. It should be noted that state law is the primary basis for the definition of legal patient record

Question 40

Issues Impacting the Electronic Legal Health Record

Answer 40

The content of the legal record must be defined in facility policy and standards for maintaining the security and integrity of the record need to be clearly defined. In a hybrid record system, part of the records will be retrieved manually while the remaining part will be housed in the automated system. It is essential that all parts of the record, regardless of the media used to store it, be addressed in facility policy.

Question 41

Record Transitional Template

Answer 41

A document that delineates the various sources of the component parts of the patient record

Question 42

It is important for HIM professionals to what?

Answer 42

To identify that manner in which the documents are final saved and to develop policies that facilitate a complete and accurate records.

Question 43

Other EHR System issues

Answer 43

IN a paper systems the documents are viewed manually. How to print an entire record, how it will look,

Question 44

HIM professionals do not have to….

Answer 44

manually complete a task. Instead, they have to monitor the task to ensure completion by clinicians.