DPRC Final Exam Flashcards
JCAHO published “To Err is Human” T/F
False
Missing, inaccurate, and illegible data has led to many patient’s deaths. T/F
True
Paper records are more effective than electronic records in integrating inpatient and ambulatory data. T/F
False
In a robust EMR, the provider should be able to print out patient education materials. T/F
True
E-Prescribing involves sending a prescription from the physician’s offic to the pharmacy. T/F
True
A SOAP note is a form of Encounter Note. T/F
True
Encounter notes should not used pre-defined templates because they limit the physician’s ability to record patient-specific information. T/F
False
Structured data entry ensures the consistency of data. T/F
True
Because of security concerns, physicians should not access patient data remotely when not in their offices.
False
An EMR system can prompt a user for reasonableness of a blood pressure recording. T/F
True
The “P” in CPOE stand for Physician”. T/F
False
WHO is responsible for ICD-14. T/F
False
IOM stands for
Institute of Medicine
The author of “Crossing the Quality Chasam” was
IOM
IOM goals for quality included what?
Safety and equity
Timeliness and patient-centeredness
Effectiveness and efficiency
How is downtime related to electronic records?
Ensured the network is encrypted
A synonym for “medical evidence” or evidence-based a medicine
Best practice
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.
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
A
Which of the following would appear in the patient’s clinical record?
- problems, medications, dates, and reasons for past visits
- laboratory results, clinical notes, demographic information
- Age, occupation, past medical history
- Medical Status, age, sex
Which of these can substantially reduce medication error rate
a. CPOE
b. BCMA
c. CPOE and BCMA
d. None of the above
c. CPOE and BCMA
Which of the following is NOT a provider?
a. Registrar
b. Oncologist
c. Respiratory Therapist
d. Physician Assistant
a. Registrar
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
d. all of the above
Which data would be utilized in a CPOE function?
a. patient allergy data
b. medication dose
c. current medication list
d. all the above
d. all the above
CPOE is an example of
a. clinical decision support
b. generation of clean billing data
c. administrative security
d. encryption
a. clinical decision support
With a digital patient record, the patients’s information can be shared and moved more easily than a paper record. T/F
True
CPOE can provide
a. dosing suggestions
b. dosing suggestions and contraindications
c. dosing suggestion, contraindications, and advice
d. None of the above
c) dosing suggestions, contraindications, and advice
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
c) a. improved legibility of data and b. reduced cost of research
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
c) a. possibility of the system interfering with the patient/physician relationship during visit & b. restrictive data templates
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) consists of a set of standardized terms and b. may contain synonyms
This is a clinical terminology originally created by CAP (College of American Pathology)
SNOWMED CT
This organization documents standards for abbreviations in documentation.
JCAHO
This organization has written landmark studies focused on quality of care
IOM
This organization might be responsible for exchanging healthcare data across state boundries
RHIO
This function of an EMR is only used by licensed providers
CPOE
Standardized clinical terminology a. is not needed for data exchange b, is limited to laboratory dat c. includes DICOM d, includes RLMN
C. includes DICOM
This organization grants RHIT certification
AHIMA
Supports clinical data managed by the patient
PHR
Supports clinical data in one health care organization
EMR
Supports movement of data among organizations
HIE
Supports clinical data across more than health care organization
EHR
Supports sharing clinical data in a defined geographic area
RHIO
An HIS is only utilized in a large medical center. True and False
False
Health information system were originally developed to support administrative functions. True or False
True
An administrative function in HIS would include the recording of charges with associated codes that represent symptoms, disease, tests, and treatments. True/False
False
Recording insurance information is a departmental function. True/False
True
The government agency that oversees Medicare and Medicaid is CMG. True/False
False
An iEHR enables patient to view provider-based data as well as PHR data. True/False
True
An iEHR usually requires a “Portal.”
True
A DRG is measure of quality. True/False
False
CPOE helps to prevent errors of commission as well as errors of omission. True/False
True
Only nursing performs and documents assessments. True/False
False
Charting is a synonym for documenting information. True/False
True
Clinical documentation is an administrative function. True/False
False
BCMA and BPOC are synonyms
True
The Charge Master can provide information about charges to other HIS modules. True/False
True
A payroll system is often a component of a human resources system and can interface with Time ans
Attendance
True
AMIA is the American Medical Informatics Association. True/False
True
A centralized HIS will have fewer vendors than a Best of Breed environment. True/False
True
E-Prescribing includes printing out the prescriptions as well as educational materials about the drug. True/False
True
An HIS includes what type of software?
hardware, software, records, policies, and procedures, people who manage it.
Age, date of birth, and telephone number are
examples of demographic information
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
c. resolving duplicate medical records numbers
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
c. The entire record will not be held in one place for all time.
The T in ADT stands for
Transfer
You would see chemistry, hematology, microbiology, and toxicology within which system
LIS (Laboratory Information System)
Scheduling, result reporting, and image tracking would be seen in which system?
RIS (Radiology Information System)
What system stores medical images?
PACS (Picture Archiving
The A in PACS stand for
Archiving
What system generates medication label?
Pharmacy
What system “tight” integration with clinical ordering function?
Pharmacy
Which of these is NOT a departmental system?
a. LIS
b. RIS
c. Pharmacy
d. Billing
d. Billing
A clinical system can perform what type of checks
drug-allergy, drug-laboratory value checks, drug-drug interaction checks
PRN means pro re nata (Latin) which means
as needed
Clinical Decision Support supports
just-in-time decision making
Charges, bills, payers insurance would be seen in what system
Billing
What system would track hours worked
Time and Attendance
In a Best of Breed environment, what is a requirement
interfaces
How many recommended HIS functions are there
140
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
c. Use of EMR in Home Health is prohibitively expensive.
Tracks where he patient s in a hospital
ADT
Requries coding to calculate
DRG
A database within an HIS
MPI
Physician sees an alert for a critical laboratory is this an example of Clinical Decision Support
Yes
back office receivables clerk sees an alert for a late payment is this an example of Clinical Decision Support
No
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
Yes
Physician reviews past history information is this an example of Clinical Decision Support
No
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
Yes
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
Yes
Automates purchasing and ordering of supplies
Materials Management
Usually a component of an HR (Human Resources)
Time and Attendance
May include EDI capability to send data to clearinghouses
Billing
Interface to Payroll
Time and Attendance
Who can enter vital signs
Nurses Aid
Who completes an encounter form
Physician
Who validates a CPOE order
Pharmacist
Who must sign a medication order
Physician
Who updates the demographic information
Registrar
In an inpatient setting, a Census function displays a list of patients and where they are. True/False
True
A cover sheet is not used to verify that a user has selected the right patient. True/False
False
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
True
It is good practice to have more than one unique medical record number for the patient. True/False
False
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
True
Chemistry, microbiology/virology, and blood bank are divisions of laboratory. True/False
True
A new AHIMA standard removes the requirement that an authenticated documented have a date and a time associated with the signature. True/False
False
If an entry to an electronic entry has been modified, there should be a symbol that indicates there is additional information. True/False
True
What function can be used to locate a patient?
search
In an inpatient environment, a nurse or physician might first select a clinical group _______ _______ to locate a patient.
care area
After the patient as been selected, what is the first screen display in an inpatient setting?
patient cover sheet
A _______identifier must be used to identify and verify the patient.
strong
Name a few tabs that may be represented in a clinical system?
Notes, Laboratory, and Past Events
What is a D-dimer
blood sample taken from a patient and processed in the lab
Radiology reports might be organized by
type of test and body system
PET in a clinical record would indicate a/ an
diagnostic test
A Reference Interval
Indicates what is normal for the laboratory device used
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 “
PACS
Which organization creates and maintains HIT standards
HL7
A legally authenticated document can (name two things)
can be signed manually and electronically
Entries by nursing students and medical students must be
co-signed
A documentation entry that states “ patient is annoying and obnoxious and belongs in a nut house does what
violates a JCHAO standard and violates professional standards
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
d. None of the statements are false
What information would be on an audit trail or log for entries in the EHR/EMR
the user date and time, the user ID, the record modified
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.
d.
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
b. aggregate data
When an EMR is utilized to capture information about potential epidemics, the process is called
biosurveillance
A record that is a combinations of paper and an electronic record is called a/an
hybird
When a respiratory therapist orders medications in a computer system, the function is called
Computerized Provider Order Entry
When a computer system issues alerts and warnings that a medication may be dangerous to the patient, the capability is called
Clinical Decision Support
Laboratory and System ________ results data to an EHR
intergrate
A collection of record made available statistical is called a
registry
The organization that publishes the standards for use of abbreviation
JCAHO
The process of ______ scrambles and unscrambles data and documents utilizing a _______
encryption and key
A ________ is an _________ ________ that records changes to data
log, audit trail
A system that contains data only for outpatients is an ___________ system
ambulatory system
When a physician writes a prescription and the system electronically transmit the prescription to the pharmacy, the function is
e-prescrbing
A password with 8 characters and a combination of upper and lowercase letters, numbers, and special symbols is called ________ password
strong
