Health Clinical Exam #1 Flashcards
Interoperability
The ability of software or systems to make use of information and exchange with other providers, facilities, etc.
Point of Care
Occurs at time patient is being seen, through speech or voice recognition. It is like taking notes while listening to the patient.
Duplicate patient registration entries
Each patient is only entered ONCE in a hospital or facility.
Database
Allows for documentation in clinical and administrative data on one platform. This results in better coordination of care for the patient and allows concentration on patient care. Also known as patient list.
Master Patient Index
Permanent listing of all patients who have received care in hospital setting, in patient or outpatient. This prevents duplication of records. You are also able to pull this up by social
Encounter
How many times you have been to the establishment
Clinical providers cost increases for EHRs-
Hardware and equipment can be costly. Also, training on software and planning for implementation can be costly.
Service providers cost increases for EHRs
These are who are paying for research and development of products so it is very costly. It cost more than it does for clinical providers.
What are the 3 covered entities?
Health Plans, Health Care Clearing Houses, Health Care Providers
Health Plans
Usually a group plan that pays for or provides medical care.
Health Care Clearing Houses
A public or private entity that processes patient data into a standardized billing format and checks for inconsistencies or errors in that data.
Health Care Providers
The provider of medical or health services.
Clinical Functions:
Includes information like chief complaint, vital signs, physical exams and pt history. This is patient medical information and is very important.
Financial Functions:
Complete billing claim form and sending insurance claims to correct insurance company.
Administrative Functions:
Filing claims, revenue management, collecting patient demographics.
Clinical and Administrative functions are:
Reported separately in patient records.
Registration:
The process of getting to know the patient. In a clinical setting, it can be done either through a registration form or verbally. The health provider may ask or even fill out a form for: name, social, DOB, marital status, race, insurance, etc., to get to know the patient before proceeding to the scheduling process.
Admission:
Known as approving a patient into the healthcare facility. In a clinical setting, sometimes registration determines if a patient is admitted. However, if they are admitted, they can get the treatment they need.
Discharge:
Is known as the patient leaving the healthcare facility once treated. In a clinical setting once the patient is treated, patients go home with additional information of their treatment such as a pamphlet or notes. This is important to ensure the treatment process is going well.
Transfer
The process when a patient might have to move to another healthcare facility. In a clinical setting, there may be times that doctors/nurses might need another sample or need to have additional labs run to figure out the problem, so patients might be transferred to a different department.
National Providers Identifier (NPI) number
Usually 10 digits that is used on insurance claims to let the insurance know who rendered care to the patient. This number is also issued out by the Centers for Medicare & Medicaid services. Used in a clinical setting when filling out the insurance claim.
National Health Information Network
Also know as NHIN, is policies, service, and standards that secures the exchange of HI. This is used in a clinical setting as healthcare workers must exchange patients’ data over the internet.
HIPAA:
Also known as the Health Insurance Portability and Accountability Act, is an act that is used in HI to protect and secure patient information. It also helps people who lost their job to find another insurance or keep their insurance with a pre-existing condition. This act is very important because in healthcare, confidentiality and privacy of patient information is a big part of healthcare.
Office of the National Coordinator (OCR)
An entity in charge of the implementation, coordination, and use of HIT and HIE. Supports the promotion of HIT nationwide.
HITECH Act
The Health Information Technology for Economic and Clinical Health, is an act apart of the American Recovery and Reinvestment Act (ARRA). This act applies to the clinical setting as it encourages healthcare facilities to use an EHR using incentives.
Protected Health Information (PHI)
Used in a clinical setting to help identify patients. This health information is protected by HIPAA.
Clinical Decision Support Software (CDSS)
It is a software physicians use. It’s used in a clinical setting to help decide the right treatments for their patients and medications, disease information, and flag certain elements in a patient’s portal to let the physician know that they need to act quickly.
What does a Health information Manager do?
Focus on health information and oversees its privacy, security, and accuracy.
What does a Registered Health Information Administrator (RHIA) do?
Responsible for overseeing departments and looking at how the whole organization working. RHIA’s usually has a bachelor’s or master’s degree.
What does a Information Technology Manager/Officer do ?
Oversees the IT system and manages the technology side of health information and troubleshoot any problems.
Practice Management Systems are called different things if they are used in an outpatient setting. What is this system called in the outpatient setting?
Is called either billing systems, RADT, or even Ambulatory EHR.
Face Sheet
It is normally found in the EHR clinic. The face sheet lists all the information about the patients such as allergies, immunizations, medical history, etc. It’s basically a chart that shows all the information about the patient.
Registration page
A form that is given to the patient to get all their information such as name, race, religion, age, insurance, etc.
Person Health Record (PHR)
The patient’s personal documentation of their signs, symptoms, and progression/improvements. This record gets data input from the actual patient and the patient can decide what to include and what not to include. This record does not replace the EMR.
Capturing:
Is in relation to data as you must find the raw facts first. In healthcare, healthcare workers get this information verbally or written by a patient and enter this data on the patient profile.
Detailing
In relation to data as digging deeper into the data turns into information and knowledge. Adding context to data makes the data more meaningful, and adding knowledge helps figure out the problem.
Gathering
Relation to data as you must look at all the facts together, whether to observe correlation or patterns.
Retrieving
is in relation to data as in healthcare, workers must retrieve the data entered to complete their task.
Data
The raw facts with no explanation whereas information is raw facts with added context/detail. A
Structured Data
In a specific format, and easier to track. An example would be ICD-10 codes. They are in a specific format; they never change, and they can be tracked.
Unstructured Data
Not in a specific format and is harder to track. An example would be physician notes as they are hard to keep track of or even audio files. Audio files can be changed or even the speech recognition for the files can be wrong and lead to misinformation.
