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EHRC > DPRC Final Exam > Flashcards

DPRC Final Exam Flashcards

0
Q

JCAHO published “To Err is Human” T/F

A

False

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1
Q

With a digital patient record, the patients’s information can be shared and moved more easily than a paper record. T/F

A

True

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2
Q

Missing, inaccurate, and illegible data has led to many patient’s deaths. T/F

A

True

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3
Q

Paper records are more effective than electronic records in integrating inpatient and ambulatory data. T/F

A

False

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4
Q

In a robust EMR, the provider should be able to print out patient education materials. T/F

A

True

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5
Q

E-Prescribing involves sending a prescription from the physician’s offic to the pharmacy. T/F

A

True

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6
Q

A SOAP note is a form of Encounter Note. T/F

A

True

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7
Q

Encounter notes should not used pre-defined templates because they limit the physician’s ability to record patient-specific information. T/F

A

False

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8
Q

Structured data entry ensures the consistency of data. T/F

A

True

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9
Q

Because of security concerns, physicians should not access patient data remotely when not in their offices.

A

False

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10
Q

An EMR system can prompt a user for reasonableness of a blood pressure recording. T/F

A

True

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11
Q

The “P” in CPOE stand for Physician”. T/F

A

False

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12
Q

WHO is responsible for ICD-14. T/F

A

False

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13
Q

IOM stands for

A

Institute of Medicine

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14
Q

The author of “Crossing the Quality Chasam” was

A

IOM

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15
Q

IOM goals for quality included what?

A

Safety and equity
Timeliness and patient-centeredness
Effectiveness and efficiency

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16
Q

How is downtime related to electronic records?

A

Ensured the network is encrypted

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17
Q

A synonym for “medical evidence” or evidence-based a medicine

A

Best practice

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18
Q

A registered vocabulary of HL7 incorporated into the National Library of Medicine’s Unified Medical Language System in 1998, describing the procedures, treatments, and services provided during an encounter with complementary and alternative medicine, nursing , and other integrative healthcare provider.

A

ABC Codes

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19
Q

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

A

A

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20
Q

Which of the following would appear in the patient’s clinical record?

A
  1. problems, medications, dates, and reasons for past visits
  2. laboratory results, clinical notes, demographic information
  3. Age, occupation, past medical history
  4. Medical Status, age, sex
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21
Q

Which of these can substantially reduce medication error rate

a. CPOE
b. BCMA
c. CPOE and BCMA
d. None of the above

A

c. CPOE and BCMA

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22
Q

Which of the following is NOT a provider?

a. Registrar
b. Oncologist
c. Respiratory Therapist
d. Physician Assistant

A

a. Registrar

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23
Q

Which of the following can an EHR system do to ensure data qualify?

a. make sure the value is one of a predefined list
b. make sure the data has been entered
c. make sure the data has been authenticated
d. all the above

A

d. all of the above

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24
Q

Which data would be utilized in a CPOE function?

a. patient allergy data
b. medication dose
c. current medication list
d. all the above

A

d. all the above

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25
Q

CPOE is an example of

a. clinical decision support
b. generation of clean billing data
c. administrative security
d. encryption

A

a. clinical decision support

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27
Q

CPOE can provide

a. dosing suggestions
b. dosing suggestions and contraindications
c. dosing suggestion, contraindications, and advice
d. None of the above

A

c) dosing suggestions, contraindications, and advice

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28
Q

Which of the following are benefits of EMR?

a. improved legibility of data
b. reduced cost of research
c. a and b
d. a only

A

c) a. improved legibility of data and b. reduced cost of research

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29
Q

Drawbacks associated with an EMR include

a. possibility of the system interfering with the patient/physician relationship during a visit
b. restrictive data entry templates
c. a and b
d. b only

A

c) a. possibility of the system interfering with the patient/physician relationship during visit & b. restrictive data templates

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30
Q

Clinical terminology utilized in an EMR

a. consists of a set of standardized terms
b. may contain synonyms
c. a only
d. a and b

A

a) consists of a set of standardized terms and b. may contain synonyms

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31
Q

This is a clinical terminology originally created by CAP (College of American Pathology)

A

SNOWMED CT

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32
Q

This organization documents standards for abbreviations in documentation.

A

JCAHO

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33
Q

This organization has written landmark studies focused on quality of care

A

IOM

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34
Q

This organization might be responsible for exchanging healthcare data across state boundries

A

RHIO

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35
Q

This function of an EMR is only used by licensed providers

A

CPOE

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36
Q 
Standardized clinical terminology
a. is not needed for data exchange
b, is limited to laboratory dat
c. includes DICOM
d, includes RLMN
A

C. includes DICOM

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37
Q

This organization grants RHIT certification

A

AHIMA

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38
Q

Supports clinical data managed by the patient

A

PHR

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39
Q

Supports clinical data in one health care organization

A

EMR

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40
Q

Supports movement of data among organizations

A

HIE

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41
Q

Supports clinical data across more than health care organization

A

EHR

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42
Q

Supports sharing clinical data in a defined geographic area

A

RHIO

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43
Q

An HIS is only utilized in a large medical center. True and False

A

False

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44
Q

Health information system were originally developed to support administrative functions. True or False

A

True

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45
Q

An administrative function in HIS would include the recording of charges with associated codes that represent symptoms, disease, tests, and treatments. True/False

A

False

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46
Q

Recording insurance information is a departmental function. True/False

A

True

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47
Q

The government agency that oversees Medicare and Medicaid is CMG. True/False

A

False

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48
Q

An iEHR enables patient to view provider-based data as well as PHR data. True/False

A

True

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49
Q

An iEHR usually requires a “Portal.”

A

True

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50
Q

A DRG is measure of quality. True/False

A

False

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51
Q

CPOE helps to prevent errors of commission as well as errors of omission. True/False

A

True

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52
Q

Only nursing performs and documents assessments. True/False

A

False

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53
Q

Charting is a synonym for documenting information. True/False

A

True

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54
Q

Clinical documentation is an administrative function. True/False

A

False

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55
Q

BCMA and BPOC are synonyms

A

True

56
Q

The Charge Master can provide information about charges to other HIS modules. True/False

A

True

57
Q

A payroll system is often a component of a human resources system and can interface with Time ans
Attendance

A

True

58
Q

AMIA is the American Medical Informatics Association. True/False

A

True

59
Q

A centralized HIS will have fewer vendors than a Best of Breed environment. True/False

A

True

60
Q

E-Prescribing includes printing out the prescriptions as well as educational materials about the drug. True/False

A

True

61
Q

An HIS includes what type of software?

A

hardware, software, records, policies, and procedures, people who manage it.

62
Q

Age, date of birth, and telephone number are

A

examples of demographic information

63
Q

What is NOT a clinical function

a. taking of vital signs
b. recording past medical history
c. resolving duplicate medical records numbers
d. reviewing laboratory results

A

c. resolving duplicate medical records numbers

64
Q

Which statement is true about Lifelong, longitudinal or continuity of care patient record.
a. Providers can purchase one from a variety of healthcare technology vendors
b. There are clear standards for the elements of a summary record.
c. The entire record will be held in one place for all time
d, There is a national MPI that is used with Longitudinal Patient records

A

c. The entire record will not be held in one place for all time.

65
Q

The T in ADT stands for

A

Transfer

66
Q

You would see chemistry, hematology, microbiology, and toxicology within which system

A

LIS (Laboratory Information System)

67
Q

Scheduling, result reporting, and image tracking would be seen in which system?

A

RIS (Radiology Information System)

68
Q

What system stores medical images?

A

PACS (Picture Archiving

69
Q

The A in PACS stand for

A

Archiving

70
Q

What system generates medication label?

A

Pharmacy

71
Q

What system “tight” integration with clinical ordering function?

A

Pharmacy

72
Q

Which of these is NOT a departmental system?

a. LIS
b. RIS
c. Pharmacy
d. Billing

A

d. Billing

73
Q

A clinical system can perform what type of checks

A

drug-allergy, drug-laboratory value checks, drug-drug interaction checks

74
Q

PRN means pro re nata (Latin) which means

A

as needed

75
Q

Clinical Decision Support supports

A

just-in-time decision making

76
Q

Charges, bills, payers insurance would be seen in what system

A

Billing

77
Q

What system would track hours worked

A

Time and Attendance

78
Q

In a Best of Breed environment, what is a requirement

A

interfaces

79
Q

How many recommended HIS functions are there

A

140

80
Q

Which of these statement is NOT true?

a. An EHR can be utilized in Home Health
b. Data can be sent from a home instrument like glucometer to an EHR
c. Use of EMRs in Home Health is prohibitively expensive
d. EHR is a component of every Home Health System

A

c. Use of EMR in Home Health is prohibitively expensive.

81
Q

Tracks where he patient s in a hospital

A

ADT

82
Q

Requries coding to calculate

A

DRG

83
Q

A database within an HIS

A

MPI

84
Q

Physician sees an alert for a critical laboratory is this an example of Clinical Decision Support

A

Yes

85
Q

back office receivables clerk sees an alert for a late payment is this an example of Clinical Decision Support

A

No

86
Q

Physician sees a message that the diabetic patient in the office has not had a retinal exam in 5 years is this an example of Clinical Decision Support

A

Yes

87
Q

Physician reviews past history information is this an example of Clinical Decision Support

A

No

88
Q

Respiratory therapist alerted that a patient has had an adverse reaction to a drug a specialist has prescribed is this an example of Clinical Decision Support

A

Yes

89
Q

Pharmacist is alerted that a patient has had an adverse reaction to a drug a specialist has prescribed is this an example of Clinical Decision Support

A

Yes

90
Q

Automates purchasing and ordering of supplies

A

Materials Management

91
Q

Usually a component of an HR (Human Resources)

A

Time and Attendance

92
Q

May include EDI capability to send data to clearinghouses

A

Billing

93
Q

Interface to Payroll

A

Time and Attendance

94
Q

Who can enter vital signs

A

Nurses Aid

95
Q

Who completes an encounter form

A

Physician

96
Q

Who validates a CPOE order

A

Pharmacist

97
Q

Who must sign a medication order

A

Physician

98
Q

Who updates the demographic information

A

Registrar

99
Q

In an inpatient setting, a Census function displays a list of patients and where they are. True/False

A

True

100
Q

A cover sheet is not used to verify that a user has selected the right patient. True/False

A

False

101
Q

In an EHR system, the patient may have more than one record, each with a different account number but the same Medical Record number. True/False

A

True

102
Q

It is good practice to have more than one unique medical record number for the patient. True/False

A

False

103
Q

In an inpatient environment that uses paper, navigation is supported using tabs; in an electronic environment navigation is supported using and electronic equivalent of a “tab”. True/False

A

True

104
Q

Chemistry, microbiology/virology, and blood bank are divisions of laboratory. True/False

A

True

105
Q

A new AHIMA standard removes the requirement that an authenticated documented have a date and a time associated with the signature. True/False

A

False

106
Q

If an entry to an electronic entry has been modified, there should be a symbol that indicates there is additional information. True/False

A

True

107
Q

What function can be used to locate a patient?

A

search

108
Q

In an inpatient environment, a nurse or physician might first select a clinical group _______ _______ to locate a patient.

A

care area

109
Q

After the patient as been selected, what is the first screen display in an inpatient setting?

A

patient cover sheet

110
Q

A _______identifier must be used to identify and verify the patient.

A

strong

111
Q

Name a few tabs that may be represented in a clinical system?

A

Notes, Laboratory, and Past Events

112
Q

What is a D-dimer

A

blood sample taken from a patient and processed in the lab

113
Q

Radiology reports might be organized by

A

type of test and body system

114
Q

PET in a clinical record would indicate a/ an

A

diagnostic test

115
Q

A Reference Interval

A

Indicates what is normal for the laboratory device used

116
Q

A diagnostic imaging test is performed in Philadelphia at midnight. It is immediately “read” and resulted in Israel. What technology is the radiologist using to “

A

PACS

117
Q

Which organization creates and maintains HIT standards

A

HL7

118
Q

A legally authenticated document can (name two things)

A

can be signed manually and electronically

119
Q

Entries by nursing students and medical students must be

A

co-signed

120
Q

A documentation entry that states “ patient is annoying and obnoxious and belongs in a nut house does what

A

violates a JCHAO standard and violates professional standards

121
Q

Which statement is false

a. Corrections to a record must be signed and dated
b. The original entry as well as the correction to record must be viewable
c. In some situations, information in a patient record can be erased
d. None of these statements is false

A

d. None of the statements are false

122
Q

What information would be on an audit trail or log for entries in the EHR/EMR

A

the user date and time, the user ID, the record modified

123
Q

Which of the following is not true

a. A hospital birth results in creation of a new medical record number
b. An unidentifiable patient will inititally have a new MR
c. The organization MUST have policies for creating new MR
d. None. All statements are true.

A

d.

124
Q

A physician who works for a state public health agency is reviewing a report that shows the incidence if highly infectious virus. The report shows ED Admission date, patient diagnosis, and zipcode. This is an example of

A

b. aggregate data

125
Q

When an EMR is utilized to capture information about potential epidemics, the process is called

A

biosurveillance

126
Q

A record that is a combinations of paper and an electronic record is called a/an

A

hybird

127
Q

When a respiratory therapist orders medications in a computer system, the function is called

A

Computerized Provider Order Entry

128
Q

When a computer system issues alerts and warnings that a medication may be dangerous to the patient, the capability is called

A

Clinical Decision Support

129
Q

Laboratory and System ________ results data to an EHR

A

intergrate

130
Q

A collection of record made available statistical is called a

A

registry

131
Q

The organization that publishes the standards for use of abbreviation

A

JCAHO

132
Q

The process of ______ scrambles and unscrambles data and documents utilizing a _______

A

encryption and key

133
Q

A ________ is an _________ ________ that records changes to data

A

log, audit trail

134
Q

A system that contains data only for outpatients is an ___________ system

A

ambulatory system

135
Q

When a physician writes a prescription and the system electronically transmit the prescription to the pharmacy, the function is

A

e-prescrbing

136
Q

A password with 8 characters and a combination of upper and lowercase letters, numbers, and special symbols is called ________ password

A

strong

EHRC (10 decks)

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