EHR Final Study Guide

Question 1

What is CPT?

Answer 1

Current procedural terminology is a coding system, used to convert narrative, procedures, and services into numerical form.

Question 2

What is international classification of diseases 10th revision clinical modification?

Answer 2

ICD 10 CM is the classification system used to convert narrative diagnoses into alpha numerical codes in all healthcare settings.

Question 3

What is a point of care?

Answer 3

Documentation dictation and ordering of tests and procedures that occur at the same time the patient is being seen.

Question 4

What does a CPT manual do?

Answer 4

Procedures and services are found here

Question 5

What is a clinical decision support?

Answer 5

CDS is an electronic application that allows access to current treatment options for a disease through electronic or remote methods. Alerts to care provider to possible med interactions, gives treatment options, based on the results of clinical trials or research, and alerts the provider that a patient may have a particular diagnosis based on the data found in the patient’s electronic record.

Question 6

Where is the patient education located within the EHR software?

Answer 6

Clinical decision support

Question 7

What does HIPAA regulate?

Answer 7

Affords people who left their jobs, the ability to keep their health insurance, or obtain new insurance, even with pre-existing conditions. It also sets standards for several aspects of storing, maintaining, and sharing electronic health info, while ensuring the privacy and security of health information.

Question 8

What is structured data?

Answer 8

Data that fits into a particular model or format, which can be tracked and may be part of a database. Examples include ICD 10 CM/PCS codes, CPT codes, a patient’s temp or patient’s age.

Question 9

What does HL7 do?

Answer 9

It’s a set of standards that make sharing of data between or among healthcare entities possible. It allows different software packages to interface with one another, and allows them to share data. When one update some thing it’s reflected in all shared.

Question 10

What is a CMS 1500?

Answer 10

A form used by a physicians office or other outpatient setting to submit insurance claims.

Question 11

What is a chief complaint?

Answer 11

The reason for which a patient has made an appointment, and usually in his or her own words.

Question 12

Examples of a chief complaint include____.

Answer 12

I have a sore throat

Question 13

What is inter-operability?

Answer 13

Mini different functions can take place and info can be shared between computer systems, or within applications of the same computer system, which is not possible with a manual or a paper record system.

Question 14

What is continuity of care?

Answer 14

Seamless transfer of care from one patient care provider to another.

Question 15

What does a patient’s medical history include?

Answer 15

Any surgeries, past diagnoses and treatment, allergies, illnesses, and current diagnoses, immunizations, and results of physical exams and tests.

Question 16

Example of review of systems.

Answer 16

A body system by body system, inventory of any symptoms. The patient is having or has had based on a series of questions asked by the provider.

Question 17

What is cloning and what are the possible negative outcomes of it?

Answer 17

It is used in an electronic environment, copying, similar or identical information from a previous encounter of the same or different patient. It’s dangerous if incorrect medication, prior or current treatments, or past history is our incorrectly carried over to a patient’s record. It is also important to remember it serves as a basis for medical decision making, and it is a record upon which legal decisions are based in cases of medical malpractice, liability, and workers compensation.

Question 18

The chief complaint goes where in the SOAP note?

Answer 18

Subjective

Question 19

What is real time data?

Answer 19

Info that is available as soon as it’s created an acquired. Scribes, medical, dictation in transcription, speech and voice, recognition tech, and electronic prescribing.

Question 20

What is a problem list?

Answer 20

A list kept in the patient’s health record of all his, or her current (active) and resolved medical conditions.

Question 21

What is an example of objective data?

Answer 21

Temperature of 100.6°F.

Question 22

Example of plan of care.

Answer 22

Order a strep, test, and prescribe antibiotics if strep test is positive.

Question 23

What is HPI (history of present illness)?

Answer 23

The patient’s depiction of his, or her current illness as told to the healthcare professional or care provider.

Question 24

What does interface mean?

Answer 24

The ability of one computer system or component to accept or send data to another system, without loss of integrity or meaning.

Question 25

What is code linkage?

Answer 25

On an insurance claim, the relationship between each procedure (CPT code) and a diagnosis (ICD 10 CM code) to demonstrate medical necessity.

Question 26

Which goes first on a CMS 1500 form, the CPT code, or the ICD 10 CM code?

Answer 26

The CPT code is first for the procedures done, and you have to prove medical necessity next with the ICD 10 CM diagnosis.

Question 27

What is an encounter form?

Answer 27

Also known as a super bill or routing slip. It is a document paper or electronic that is used in medical offices to capture the diagnoses and the services performed, and from which the CMS 1500 billing form is completed.

Question 28

What does the alert feature do in an EHR system?

Answer 28

Alerts the providers of allergies, medication, interactions, and medication errors.

Question 29

What is an explanation of benefits?

Answer 29

An explanation of the charges for services, the amount paid by the insurance company, and the amount, due by the subscriber, which is sent to the subscriber and the provider in some instances.

Question 30

Who or what handles fraudulent billing?

Answer 30

The OIG. Office of inspector general.

Question 31

What is a breach of confidentiality?

Answer 31

Releasing info without a required, properly executed authorization, or as restricted by law

Question 32

What is data integrity?

Answer 32

Maintaining the accuracy and consistency of data

Question 33

What is an audit trail?

Answer 33

A permanent record, or accounting of access is, additions, amendments, or deletions to a health record. Shows a report of accesses by user to each function of software.

Question 34

What is RBACs (role based access controls)?

Answer 34

Restrict access to areas of the patient record or info based on the job title

Question 35

What should a good password contain?

Answer 35

A combination of letters, numbers, and special characters. No less than six and no more than eight characters in length, and should be set up to prompt users to change their password. At least every 90 days.

Question 36

What is MAR/EMAR?

Answer 36

Medication administration record/electronic medication administration record. Tracks meds from order to administration.

Question 37

What is the HIPAA privacy act?

Answer 37

Outlines the circumstances in which PHI must be disclosed.

Question 38

What is benchmarking?

Answer 38

Comparison of one set of statistics to the overall statistics, when the same variables are used for each.