DPRC CERTIFICATION TEST Flashcards
A health record on a computer is known by a variety of terms, name them
Electronic health record (EHR), Electronic medical record (EMR), or Computer-based record
What’s the umbrella term developed by DPRC
Digital patient record
The __________ __________ _________ is an important and growing _________ of the modern ____________ system
Digital patient record, facet, healthcare
Healthcare facilities that use ______ ________ _______ are more likely to be __________ and less _______ to ________ errors.
digital patient record, efficient, prone, costly
Workers _______-_______ in digit patient records will ________ be ______ out by _________
well-versed, increasingly, sought, employers
PHR
Protected health record
DPRC will help you master the skills you need to work in an environment where _______ _______ information — all individually __________ ______ _______ created, _______, ______, or ______ by a healthcare _______ – can be called up on a _______ _______.
protected health, identifiable health information, transmitted, received, maintained, entity, computer screen
_______ _______ is an emerging industry, with _______ having ______ ______ in other countries.
Medical tourism, patients, major surgery
With ______ _____ ______, a_______ information can be _______ and moved more easily than with a _______ _______.
digital patient record, patient;s shared, paper record
In what year was a vision from the digital patient record created?
early 1990
What was the name of the landmark report of the Institute of Medicine titled and when was it released?
The Computer-Based Patient Record: An Essential Technology for Health care released in 1991
The vision of the landmark report by the IOM laid out a broad vision of what?
computer-based patient record that would follow a person from cradle to grave and serve the healthcare provider that cared for that patient with rich functionality.
How was the landmark report by the IOM effective?
The report was effective in establishing electronic health records as an “establishment” policy objective.
In the 1990’s EHR had generated sufficient evidence of their potential to improve the safety and quality of healthcare that two additional reports were written by the IOM name them
To Err Is Human and Crossing the Quality of Chasm
The IOM identified six goals for quality in health care systems name them
- safety
- equity
- effectiveness
- efficiency
- patient-centerness
- timeless
The IOM identified 5 strengths of paper medical records from the perspective of the record user what are they
- familiarity: users don’t have to acquire skills to use paper records
- portability: Paper records can be carried by the clinician to the patient
- No downtime: Once in hand, paper records do not experience downtime as computer systems do
- Flexibility in recording: Paper records allow flexibility in recording data and information, including subjective data
- Browsing: Paper records can be browsed through or visually scanned.
Despite the strengths paper records have weaknesses, what are they?
- Content issues
- —Missing data, inaccurate data, and illegible handwriting. Illegible handwriting has led to many well-documented injuries and deaths of patients - Poor format
- –Lack of order, logic, and organization - Poor access, availability, retrieval
- –A patient could be seen at a satellite clinic while his paper record is at another location - Lack of linkages and integration
- –Weak or non-existent integration between inpatient and ambulatory paper records
- –Lack of easy ways to view relevant medical evidence
The EHR facilitates a patient-provider encounter from start to finish. True/False
True
There are advantages of digital patient records. Before entering the exam room, the clinician can log onto the patient’s EHR, to find, among other things: such as
- active medical problems
- current medications
- past medical history
- past lab results
- recent radiology procedures, with full radiology report or thumbnail of the actual images
- allergies
- brief, pertinent demographics and social history, such as age, occupation, and marital status
- dates and reasons for past visits with full doctor’s notes
What are some advantages of EHR during the office visit
that the clinician is capable of doing?
- add to the problem list
- see options for treatment of the new problem
- print out patient education materials
- enter fully specified medication order (drug name, dose, route, and frequency)
- send the prescription to the pharmacy
- enter a desired follow-up interval
- add notes in a structured note template. which includes prompts for completeness and adherence to standards of care
Name the key advantages digital patient records have over paper records.
- Better access
- –Many physicians now routinely access much or all of the information they need to care for a patient from their office, at a hospital, or in their homes through digital patient record - Quality of data
- –Missing data can be greatly reduced by building in prompts that a clinician needs to respond to before closing the record
- –Inaccurate data can be minimized by adding simple data-checking mechanisms - Quality of care
- –The EHR can assist clinicians in providing a safe and more effective care by using CPOE.
- –legibility issues are eliminated using CPOE
- –Dosing, contraindication, and advice is presented to the provider at the time of medication ordering, resulting in safer medication orders - Continuity of care
- –Regional health information (RHIO) have formed in many states and regions facilitating the exchange of digital patient information from physician offices to hospitals, and from hospitals to complanies - Facilitation of medical, health services and public health research
- –Under proper authorization, the EHR makes higher-quality data readily available at much lower cost to researchers.
The use of CPOE, eliminating legibility issues, dosing, contraindication are example of
Quality of care which is one of the advantages of digital patient record
A registered vocabulary of HL7 incorporated into the Nation Library of Medicine’s Unified Medical Language System in 1998, describing the procedures, treatments, and services provided during an encounter with a complementary and alternative medicine, nursing, and other integrative medicine, nursing, and other integrative healthcare provider
ABC Codes
The use of computer software that automatically generates a set of medical codes for review/validation and/or use based upon clinical documentation provided by healthcare practitioners.
Computer-assisted coding (CAC)
The division of the Department of Health and Human Services that is responsible for developing healthcare policy for the United States and for administering the Medicare program and the portion of the Medicaid program; called the health Care Financing Administration prior to 2001
Center for Medicare and Medicaid Services (CMS)
A coding system developed by the dental profession; formerly called the Uniform Code pm Dental Procedures and Nomenclature
Current Dental Terminology (CDT)
A comprehensive list of descriptive terms and codes published by the American Medical Association and used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians.
Current Procedural Terminology (CPT)
A unit of case mix classification adopted by the federal government and some other payers as a prospective payment mechanism for a hospital inpatients in which disease are placed into groups because related disease and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost.
Diagnosis-related Group (DRG)
A nomenclature to standardize the diagnostic process for patients with psychiatric disorders; includes codes that correspond to ICD-9CM codes
Diagnostic and Statistical Manual of Mental Disorders (DSM)
A standard for the distribution and viewing of any digital image regardless of its source.
Digital Imaging and Communications in Medicine (DICOM)
An independent nonprofit health services research agency establish to promote safety, quality, and cost-effectiveness in healthcare to benefit the patient care through research, publishing, education, and consultation; formerly called the Emergency Care Research Institute.
ECRI
Federal agency responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, the nation’s food supply, cosmetics, and products that emit radiation.
Food and Drug Administration (FDA)
A non-profit foundation established in 1999 that, along with its practitioner association constituents coordinates terminology development in ABC codes.
Foundation for Integrative Healthcare (FIHC)
The legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs and guarantee the security and privacy of health information.
Heath Information Portability and Accountability Act (HIPPA)
A three-level classification system introduced in 1983 to standardize the coding systems used to process Medicare and Medicaid.
Healthcare Common Procedure Coding System (HCPCS)
The communications protocol that enables use of hypertext linking.
Hypertext transport protocol (HTTP)
A classification system used for reporting incidences of malignant disease
International Classification of Diseases-Oncology (ICD-O)
A classification system used in the United States to report morbidity information.
International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM)
The most recent revision of the disease classification system developed and used by the World Health Organization to track morbidity and mortality information worldwide.
International Classification of Disease, Tenth Revision (ICD-10)
A classification system developed by the World Health Organization in 2001 that describes how people live with their health conditions.
International Classification of Function, Disability, and Health (ICF)
A database protocol developed by the Regenstrief Institute for healthcare aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research.
Logical Observation Identifiers, Names, and Codes (LONIC)
A proprietary clinical terminology developed as a point-of care tool for electronic medical record documentation at the time and place of patient care.
MEDCIN
A vocabulary developed as a pragmatic, clinically validated medical terminology with an emphasis on ease-of-use data entry, retrieval, analysis, and display, with a suitable balance between sensitivity and specificity, within the regulatory environment.
Medical Dictionary for Regulatory Activities (MedDRA)
A classification of nursing diagnoses adopted by the North American Nursing Diagnosis Association. This system describes patients’ reactions to diseases rather than classifying the condition of diseasesd and disorders.
NANDA
A code set used for medical codes maintained and approved by the FDA; the code set designated by the Department of Health and Human Services for reporting drugs and biologics on standard retail pharmacy transactions.
National Drug Code (NDC)
A nonproprietary drug reference terminology that includes drug knowledge and classifies drugs, mostly notably by mechanism of action and physiologic effect.
National Drug File-Reference Terminology (NDF-RT)
The United States’ vision for a national health information infrastructure that makes secure transmission of person-specific health information from one location to another. NHIN is synonymous with the national health information infrastructure.
National Health Information Network (NHIN)
A standardized classification of interventions that nurses do on behalf of patients in all care domains.
Nursing Interventions Classification (NIC)
