healthcare documentation quiz

Question 1

CHI

Answer 1

computerized health information

Question 2

EMR

Answer 2

electronic medical record

Question 3

EHR

Answer 3

electronic health record

Question 4

EPR

Answer 4

electronic pt record

Question 5

CPR

Answer 5

computerized pt record

Question 6

PHR

Answer 6

personal health records

Question 7

PHI

Answer 7

personal health information

Question 8

PMR

Answer 8

pt medical record

Question 9

PMRI

Answer 9

pt medical information

Question 10

e-sign

Answer 10

digital signature

Question 11

EP

Answer 11

eligible professional

Question 12

EOE

Answer 12

electronic order entry

Question 13

CPG

Answer 13

clinical practice guidelines

Question 14

CPM

Answer 14

clinical performance measures

Question 15

CI

Answer 15

clinical indications

Question 16

CPOE

Answer 16

computerized physician order entry

Question 17

POC

Answer 17

point of care

Question 18

formulary

Answer 18

standard pharmacy of facility

Question 19

EBM

Answer 19

evidenced based practice

Question 20

SNOMED

Answer 20

global language of healthcare

Question 21

WOW

Answer 21

workstation on wheels

Question 22

COW

Answer 22

computer on wheels

Question 23

EHT

Answer 23

electronic health technology

Question 24

role of EHT

Answer 24

• improve the quality of health care
• prevent medical errors
• reduce health care costs
• increase administrative efficiencies
• decrease paperwork
• expand access to affordable healthcare
• maintain client privacy laws

Question 25

EH

Answer 25

eligible hospitals

Question 26

CAHs

Answer 26

critical access hospitals

Question 27

centers of medicare & medicaid services (CMS)

Answer 27

• incentive programs provide incentive payments to EP, EH, and CAHs
• as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology

Question 28

“meaningful use”

Answer 28

-using certified EHR technology in ways that can positively impact pt care

Question 29

examples of meaningful use

Answer 29

• CPOE for medication orders
• record VS
• medication reconciliation
• advance directives
• recoding smoking status
• active medication list

Question 30

healthcare outcomes

Answer 30

• improve quality, safety, efficiency, and reduce health disparities
• engage pts and families in their healthcare
• improve care coordination
• ensure adequate privacy and security protections for PHI
• improve individual and community health

Question 31

EHR/EMR include this important info

Answer 31

• immunizations
• allergies
• demographics
• advanced directives
• appts
• insurance/fin info
• MD orders
• H&P
• nurse charting
• current meds
• lab/dx test restults
• adjunct care
• consults

Question 32

levels of automation

Answer 32

• administrative (pt info, address, contacts, insurance, billing, etc)
• clinical date repository (basic clinical documentation)
• barcode medication
• ancillary orders/reports: lab, dx, radiology
• healthcare personnel communications
• pt portals
• MD access from mobile devices
• able to predict and address epidemic issues for any area using historical data and other factors

Question 33

clinical vocabulaires

Answer 33

• use of a standardized vocab
• ex: leukopenia vs low white blood count
• without this, an automated system cannot recognize terms as being equivalent when queried