DPRC Session 6 and 7 Full Question Bank Flashcards
In a centralized HIS, the majority of systems are manufactured by the same vendor.
True
RIS supports the function of specimen collection.
False
PACS stands for Personal Archiving and Communication System
False
The definition of an HIS includes software and hardware but not policies.
False
In a best of breed environment, there would be more interfaces than in a centralized HIS
True
An Inpatient History and Physical and Discharge Summary are complete when signed by a nurse.
False
E-Prescribing requires communication between the physician and commercial pharmacy.
True
A nursing assessment might be focused on reducing preventable events like falls and skin breakdown
True
A surgery checklist can be automated and can prevent serious medical error
True
A synonym for EBM is “Best Practice.”
True
Department scheduling would most likely be seen in
- Radiology
- Surgery
- Pharmacy
Radiology and Surgery
Medication Reconciliation is performed at
Admission, Discharge and Transfer
Formulary refers to
list of approved drugs
Which is an example of medication management?
a. SNOWMED
b. BCMA
c. HIE
d. IDE
BCMA
Which are functions you might see in a Medical Records department
- analysis
- completion
- coding
- release of information
All four
A CDS module might do which of the following?
be used to improve compliance with vaccinations
The MPI module assigns which of the following in a hospital system.
a. room and bed
b. medical record number
c. unique account number
d. bill number
medical record number
The first word in the abbreviation EMPI is
Enterprise
What department manages giving copies of a record to an individual authorized to receive it.
Medical Records
In which department system would you see divisions of toxicology and hematology?
LIS
Medication Reconciliation is done at
For every transition of care
Which department (s) has the responsibility for managing the integritiy of patient records?
Medical Records Department
The masterfile in the patient accounting system that contains items, description, and charges is the
CDM
Stores Diagnostic Images
EDI
Stores images of documents
Documenting Imaging
Processes specimens
LIS
Is connected to automated instruments
LIS
Generates an Income Statement and Balance Sheet
General Ledger
Manages Inventory of supplies
Materials Management
Electronic Exchange of data between payer and provider
EDI
Processes an order for a CT scan
RIS
Controls what drugs can be ordered
Formulary
Processes a CPOE order and does additional safety checks
Pharmacy
HIS
Health Information Systems
HIT
Health Information Technology
ADT stands for
Admission, Discharge, Transfer
What are the “five rights” of Medication Adminstration
- right patient
- right drug
- right dose
- right route
- right time
EBM stands for
Evidence-based Medicine
AR
Accounts Recievable
You would see blood pressure, respirations, temperature on a ________ ________flowsheet.
vital sign
BCMA
Bar-coded Medications Adminstration
List two examples of Clinical Decision Support
- system generates alerts during CPOE and E-Prescribing
2. system generates alerts during radiology procedure that patient is allergic to dye
Accidental and incidental viewing
Accidentally come across information that you should not view
Report inappropriate viewings (system logged your view in audit trail
Unauthorized access is grounds for immediate job termination
ROI
Release of information
Release of information requires the following on authorization form
Date signed Expiration date To whom information may be disclosed What is permitted to be disclosed For what purpose the information may be used
What is required by the patient for release of Psychotherapy Notes
A special authorization
Name some exceptions to disclosure statements
Court orders
Workers compensation cases
Statutory reports
Research (limited data sets)
Name some accounting disclosures
Listing of who received information about the patient as well as when, why and how the disclosure was made
Disclosure for TPO do not require accounting
HIPAA requires this document be kept for 6 years
NPP stands for
notice of Privacy practices
Name some of the Notice of Privacy Practices
Summarizes he facility privacy policies
Explains how it will use/disclose PHI
Include contact information for the privacy officer
Signed acknowledgement from patient that notice received
BAA stands for
Business Associate Agreement
What is a Business Associate Agreement and what is it for
A business associate is a person or organization that uses PHI TO PERFORM A service or function in behalf of a health entity
These are outsourced transcriptionist and coders, billing service, contracted vendors, collection agencies
BAA must be in place before disclosing PHI
What are the most common threats to systems
Loss of laptops containing PHI Employee curiosity Viruses and malware Fraud and theft Employee sabotage Loss of physical and infrastructure support Malicious hackers Malicious code Industrial espionage
What are risks associated with low cost remediation
Weak passwords No auto-log off after inactivity No use of encryption No or weak anti-virus/malware protection No or weak back-up and recovery
A scheduling system might schedule staff, equipment, and rooms.
True
