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)
A standardized classification of outcomes developed for use in all settings and with all patient populations. It was developed to evaluate the outcomes of nursing interventions.
Nursing Outcomes Classification (NOC)
A type of reimbursement system based on preset payment levels rather than actual charges billed after a service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary’s condition.
Prospective Payment System (PPS)
A nonproprietary terminology developed by the National Library of Medicine that represents drugs at the level of granularity needed to support clinical practice.
RxNorm
A comprehensive taxonomy that contains codes for identifying not only diseases and diagnoses, but also anatomy, conditions, morphology, and social factors that may affect health or treatment.
Systematized Nomenclature of Dentistry (SNODENT)
A comprehensive clinical terminology, originally created by the College of American Pathologists (CAP) and, as of April 2007, owned, maintained, and distributed by the International Health Terminology Standards Development Organization (IHTSDO), a non-for-profit association inDenmark.
Systematized Nomenclature of Medicine Clinical Terms (SNOWMED CT)
A standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement.
Terminology, clinical
A multipurpose resource that includes concepts and terms from many different developed source vocabularies.
Unified Medical Device Nomenclature System
A standard international nomenclature and computer coding system for medical devices; developed by ECRI.
Universal Medical Device Nonmenclature (UMDNS)
The United Nations’ specialized agency created to ensure the attainment by all peoples of the highest possible level of health; the international organization responsible for a number of international classifications, including The International Statistical Classification of Diseases & Related Health Problems (ICD-10) and The International Classification of Functioning, Disability & Health (ICF)
World Health Organization (WHO)
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
Electronic Health Record
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.
Electronic medical record
The electronic movement of health-related information among organization according to nationally recognized standards
Health Information Exchange
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.
Personal Health Record
An organization that oversees and governs the exchange of health-related information among organization according to nationally recognized standards. A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community. The full report from the Alliance includes the specific definitions and summarizes the deliberations and conclusions of the two work groups
Regional Health Information Organization
What are the 4 purposes of population records?
- Administrative and or business operations such as reimbursement for services rendered.
- Clinical groups for outcome management
- Public health/bio-surveillance
- Research
A database within an HIS containing unique identification codes for all the patients in a healthcare system
Master patient index (MPI)
Sometimes call the hotel function of healthcare information systems. Allows staff to admit pt to a healthcare facility and a specific bed, move pt to or across facilities with an enterprise and discharge pts
Admission, discharge, transfer (ADT)
Coding modules that assist medical record and other personnel to properly categorize a diagnosis so organization can get reimbursement
Diagnosis-relates group (DRG) coding
Security of medical information is the responsibility of every healthcare worker and healthcare professional. This includes:
Controlling access to a EHR or other systems that contain protected health information
Protecting the data from destruction
A log of each user and what is viewed and accessed in any amount of time.
Audit trail
Has become a critical tool for managing the security of data. Often used in detecting security violations and support for disciplinary actions. Can be a large amount of Dara in any facility.
Audit trail
When coming across records your not suppose to see what’s your responsibility? What is this called?
To use judgement and ethics. This is called Accidental viewing
People set on a criminal intent will attempt access DPR. It’s a constant threat in health information
Malicious damage
An outsider who attempts to hack or plant software viruses and worms. Often called Trojan horse programs.
Malicious damage
Accessing records without proper control. Taping passwords to monitor or walking away from a terminal without logging off threatens the security of a system.
Uncontrolled access
A non-profit professional organization of health information managers, historically the medical records professionals
American Health Information Management Association. (AHIMA)
AHIMA stands for?
American Health Information Management Association
Another word aggregate data is
Population data
A non-profit professional organization of biomedical and health informaticians, consisting of health professionals with
expertise in the appropriate use of information technology to transform health and healthcare.
American Medical Informatics Association (AMIA)
Promotes access to medical care for consumers and health professionals via telecommunications technology.
American Telemedicine Association (ATA)
A profession organization of health information management executive, e.g., those IT professionals who run systems in healthcare organizations
College of HeALth InformaTion Management Executives (CHIME)
An independent non-profit multi-stakeholder organization whose mission is to grove improvement in the quality, safety, and efficiency of healthcare through information and information technology.
eHealth Initiative (eHI)
A healthcare industry membership organization focused on providing leadership for the optimal use of healthcare information technology (IT) and management systems for the betterment of healthcare
Healthcare Information and Management Systems Society
The agency of government primarily responsible for the research and education with respect to healthcare quality and research
Agency for Healthcare Research and Quality (AHRQ0
A committee chaired by the current secretary of Health and Human Services whose aim is to speed the adoption of health information technology in America
American Health Information Community (AHIC)
A government initiative that adopts standards for domains related to health information for federal health data systems, facilitating communication among all federal health agencies.
Consolidated Health Informatics (CHI)
The office of the Secretary of Department of Health and Human Services whose responsibility it is to coordinate federal activities with respect to health information technology
Office of the National Coordinator for Health Information Technology (OTC)
The federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States.
National Center for Health Statistics (NCHS)
A public policy advisory board that recommends policy to the National Center for Health Statistics and other health-related federal programs
National Committee on Vital and Health Statistics (NCVHS)
The branch of the National Institutes of Health whose mission is to provide access to current and historical scientific information relating to health and healthcare. The site for MedLine and PubMed
National Library of Medicine (NLM)
An agency that coordinates the development of voluntary standard to increase global competitiveness in a variety of industries, including healthcare
American National Standards Institute (ANSI)
A scientific and technical organization for the development of standards on characteristics and performance of materials. The character includes products, systems and services, as well as materials, ASTM is the largest non-government source of standards in the Untied States, comprised of more than 130 committees that publish 10,00 standards annually.
American Society for Testing and Materials
A set of standards from the voluntary work participants representing all interests concerned (industry, authorities, and civil society) contributing mainly through their national standards bodies
CEN (European Committee for Standardization )
Why is the verification step important?
Because it is not uncommon to have two patients with the same last name or even the same first and last names
With the EHR, one _______ and _______ a patient record by ________ on to the EHR.
locates, verifies, logging
Depending on the setting, the _______ may have to select a ______ ______ or ______ _____ first.
user, clinical group, care area
When the user clicks OK on the patient selection screen of the digital patient record she is then see what?
The Cover Sheet
If you cannot find a patient what feature would you use to find the patient?
The search feature
What would you put in the search feature to find a patient?
A unique identifier
If one has all of the relevant record numbers for a given patient, they can be assembled electronically if there is a
master patient index
What charts by acquiring the chart?
the navigation
navigation through the record by ________ divider sheets that ______ the patient record into _________
tabbed, divide, section
Name some examples of sections of a patient record include
History/Physical, Lab, Radiology, Consults, and Progress Notes
Assisting some else to access a specific laboratory test, radiology exam or other investigation is called
viewing a result
A blood sample taken from a patient and processed by clinical lab is
D-dimer
Name some typical divisions of lab and radiology
Clinical laboratory
-anatomic pathology, microbiology, cytology, serology
Radiology
-CT, MRI, PET, molecular
Radiology departments are organized by
body system and result functions
who defines a legally authenticated document or entry as “a status in which a document or entry has been signed manually or electronically by the individual who is legally responsible for that document or entry
HL7
who recommends that an authenticated record has date and time when the individual who is legally responsible input the entry
AHIMA
when assessments are done by nursing students entries can only become legally authenticated when a supervising, legally responsible staff member does what?
co-signs
Verbal orders are discouraged because
they were found to be the cause of medical errors
The important regulatory body in the healthcare industry
JCAHO
Who states, Care is considerate and respectful of the patients’ personal values and beliefs
JCAHO
It is inappropriate for any entry to be disparaging or disrespectful to a patient or his family or friends. Who states this law
JCAHO
AHIMA recommends the following procedures in the event of an error for paper record
In a paper record:
no use of white out or black out with a marker or write over an mistaken entry
draw a line through the entry, make sure that the inaccurate information is still legible
write error by the incorrect entry in the margin or above the note
sign and date the entry
document the correct information
AHIMA recommends the following procedures in the event of an error for a EHR
most systems have the ability to track changes or corrections
the original entry should be visible
enter the current time and date
person making changes should be identified and the reason noted
the hard copy must also be corrected
a symbol that indicates a new or additional entry
a preferred method is apply a strikethrough for error with date and time and author stamp or equivalent
When might a new EGR be created and a new record number created
birth, a new pt to the organization, or accident or emergency
The organizing of clinical information, usually a database. Patient-level information is stored with many other patient information. Can as simple request such as the laboratory results for the patients I saw yesterday, evidence of toxic chemical exposure to combatants of Iraq war
aggregate patient-information
Name the four aspects of HIS
Administrative, Departmental, Clinical, Financial
Name some administrative modules of HIS
Master patient index, Admission, discharge, transfer, Disgnosis-related group coding,
Name some departmental modules of HIS
Laboratory information systems, Radiology information systems, Picture archiving and communications systems, Pharmacy
Name some clinical modules of HIS
Provider or physician order entry, clinical documentation , bar-code medication administration (BCMA), decision support
Name some financial modules of HIS
Billing, Payroll, Material management
