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stuff ni jas > his unit 6 3rd shift > Flashcards

his unit 6 3rd shift Flashcards

1
Q

Collection of computer-stored images of traditional health record documents

A

AHR Automated Health Records

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2
Q

How are AHRs stored/ collected?

A

Scanned into a computer
Stored on optical disks

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3
Q

Contains all personal health information belonging to an individual

A

EHR

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4
Q

Collection of health information for one patient linked by a patient identifier

A

CPR Computer-based Patient Record

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5
Q

What can be included in a CPR?

A

Medication orders
Integrated data on a patient’s registration
Admission and financial details
Recording information from nurses, laboratory, radiology, and
pharmacy

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6
Q

T or F: EHR extends beyond acute inpatient situations

A

T

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7
Q

EHR is entered and accessed electronically by healthcare
providers over ______

A

the person’s lifetime

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8
Q

Developed within a medical practice or health center

A

EMR

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9
Q

Describe automated systems based on document imaging or systems

A

EMR

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10
Q

What does a EMR include?

A

Include patient identification details, medications and prescription generation, laboratory results, and healthcare information recorded by the doctor

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11
Q

The EHR should reflect the ______ of an individual across his or her
lifetime including data from multiple providers from a variety of healthcare settings

A

entire health history

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12
Q

Share information with other health care providers and organizations

A

EHR

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13
Q

EMR enables clinicians to?

A

Track data over time
Easily identify who are due for screenings or checkups
Check their patients
Monitor and improve overall quality of care within the practice

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14
Q

Focus on the total health of the patient

A

EHR

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15
Q

Going beyond standard clinical data collected

A

EHR

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16
Q

Contains medical and treatment history of patients in one practice or organization

A

EMR

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17
Q

Can be gathered, managed, consulted by clinicians and staff in one healthcare organization

A

EMR

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18
Q

Conforms to interoperability standards that can be drawn from multiple sources while being shared, managed, and controlled by the individual

A

PHR

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19
Q

Conforms to nationally recognized interoperability standards
Can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization

A

EHR

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20
Q

What is the major issue that should be address before moving forward?

A

unique patient identification

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21
Q

What is the backbone of an
effective and efficient health record system, whether manual or electronic?

A

Accurate patient identification

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22
Q

Other possible issues of EHR?

A

Clinical data entry issues and lack of standard terminology

Resistance to computer technology and lack of computer literacy

Strong resistance to change by many healthcare providers

High cost of computers and computer systems and funding limitations

Concern by providers as to whether information will be available on request

Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information

Quality of electronic healthcare information and accuracy of data entries

Lack of staff with adequate knowledge of disease classification systems

Manpower issues– lack of staff with adequate skills

Environmental issues

Involvement of clinicians and hospital administrators

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23
Q

What safeguards need to be addressed?

A

Efficient back-up system available
Contingency plans for disaster recovery
Securing workstations and password requirement
Access control to authorized persons only
Audit controls

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24
Q

Staff may be available, but their skills may not be adequate
There is a need for a well-trained workforce

A

Manpower issues– lack of staff with adequate skills

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25
Q

Retention schedules
Concerned with how information is to be retrieved

A

Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information

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26
Q

Need to compare the current system costs plus perceived costs for the new EHR system

A

High cost of computers and computer systems

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27
Q

Need to adopt a standard, comprehensive vocabulary and develop a data dictionary

A

Clinical data entry issues and lack of standard terminology

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28
Q

Some prefer to write by hand
Some are still not proficient in using computers

A

Resistance to computer technology and lack of computer literacy

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29
Q

The change to entering patients’ health record data via a computer or other electronic device may be difficult.
Requires intensive training of healthcare practitioners

A

Strong resistance to change by many healthcare providers

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30
Q

Information should always be readily available can be accessed more efficiently

A

Concern by providers as to whether information will be available on request

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31
Q

What are qualities of quality data?

A

Accuracy and validity of the original source data
Reliability
Completeness
Legibility
Currency and timeliness
Accessibility

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32
Q

Limited coding training programs
Selected people who do not have a medical background

A

Lack of staff with adequate knowledge of disease classification systems

33
Q

Thorough understanding of clinical data Their specifications and input
Willingness to collaborate and share data

A

Involvement of clinicians and hospital administrators

34
Q

Electrical wiring and supply of electricity
Amount and quality of space needed for computers and other equipment

A

Environmental Issues

35
Q

Core functions of an EHR system?

A

Health information and data
Results management
Order entry and support
Decision support

36
Q

Other functions of an EHR system?

A

Electronic communication and connectivity
Patient support
Administrative processes
Reporting and population health management

37
Q

Benefits of using EHR technology?

A
  1. Improve health care quality, safety, and efficiency and reduce health disparities
  2. Engage patients and families in their health care
  3. Improve care coordination
  4. Improve population and public health
  5. Ensure adequate privacy and security of personal health information
38
Q

What is a patient portal?

A

Secure website through which patients can electronically access their medical records

39
Q

Patient portals enables users to?

A
  • Complete forms online
    ̶ Schedule appointments
    ̶ Communicate with providers
    ̶ Request refills on prescriptions
    ̶ Review test results
    ̶ Pay bills
40
Q

Factors that increase EHR adoption?

A
  • Improve patient safety
  • Reduce medical errors
  • Reduce duplicate services
  • Improve organizational efficiency
  • Optimize reimbursement
  • Complete locally and regionally
41
Q

Barriers to Adoption?

A

Financial
Organizational / Behavioral
Technical

42
Q

Use and acceptable of changes in workflow

A

Organizational / Behavioral

43
Q

Lack of capital or resources needed to develop, acquire, implement, and support a healthcare information system

A

Financial

44
Q

Work and technology needed to build system interfaces

A

Technical

45
Q

According to AHIMA (2016) what is a personal health record?

A

tool to collect, track, and share past and current information about your health or the health of someone in your care

effective tool enabling patients to be active members of their own health care teams

46
Q

T or F: PHR is managed by your healthcare provider

A

F is it not

47
Q

T or F: PHR does not constitute a legal document of care

A

T

48
Q

Should PHR contain all pertinent health care information?

A

YES

49
Q

Patient Record Content has?

A

Identification Screen
Problem List
Medical Record
History and Physical
Progress Notes
Consultation Note or Report
Physician’s Orders
Imaging and X-ray Reports
Laboratory Reports
Consent and Authorization Forms
Operative Report
Pathology Report
Discharge Summary

50
Q

Contain results of tests conducted on body fluids, cells, and tissues

A

Laboratory Reports

51
Q

Who in the lab documents any findings and treatment plans based on lab
results?

A

Physicians

52
Q

Who documents lab results into the patient record?

A

Lab personnel

53
Q

T or F: Lab Reports must be present during treatment

A

T

54
Q

Documented in a timely manner

A

Imaging and X-ray Reports

55
Q

Responsibilities of the radiologist?

A

Interpret images
Document interpretations or findings

56
Q

Identifies significant illness and operations

A

Problem List

57
Q

Used as clinical and administrative document

A

Identification Screen

58
Q

How is the problem list maintained over time?

A

By attending or primary care physician, or health care providers involved

59
Q

Made by physicians, nurses, therapists, social workers, and other staff members
Reflect patient’s response to treatment; observations and plans for continued treatment

A

Progress Notes

60
Q

What is the format for Progress Notes?

A

SOAP
Subjective findings
Objective findings
Assessment
Plan

61
Q

Practitioner who provides treatment must obtain ______

A

informed consent

62
Q

What needs the consent as alegal document?

A

STAR
Surgery
Treatment
Admission
Release of information

63
Q

Describes any surgery performed
Lists the names of surgeons and assistants

A

Operative Report

64
Q

In a Operative Report, who documents the information?

A

Surgeons

65
Q

Discharge Summary summarizes?

A
  • Reason for admission
    ̶ Significant findings from tests
    ̶ Procedures performed
    ̶ Therapies provided
    ̶ Responses to treatments
    ̶ Condition at discharge
    ̶ Instructions for medications, activity, diet and follow-up care
66
Q

Discharge summary documented by?

A

Attending physician

67
Q

Records opinions about the patient’s condition
Made by another health care provider at the request of the attending physician

A

Consultation Note or Report

68
Q

Directions, instructions, or prescriptions

A

Physician’s Orders

69
Q

Lists medicines prescribed and administered, medication allergies

A

Medical Record AKA Medication Administration Record (MAR)

70
Q

Who are responsible for documenting and maintaining information?

A

Nursing personnel

71
Q

Information originates at the time of registration or admission?

A

Name, address and telephone number
Insurance carrier
Policy number
Diagnoses and disposition at discharge

72
Q

Identifies significant illness and operations

A

Problem List

73
Q

History component describes?

A
  • Any major illnesses and surgeries the patient had
    ̶ Family history of disease
    ̶ Patient health habits
    ̶ Current medications
74
Q

What the physician found after the hands-on patient examination

A

Physical component

75
Q

Both history and physical components?

A

Document the initial patient assessment and provide basis for diagnosis and treatment

76
Q

History is provided by who and documented by who?

A

̶ Information is provided by the patient
̶ Documented by physician or other care provider

77
Q

May come from physicians and others inside or outside the organization

A

Consultation Note or Report

78
Q

Physician’s orders are given to other members of the health care team
regarding the patient’s?

A
  • Medications
    ̶ Tests
    ̶ Diets
    ̶ Treatments, and others

stuff ni jas (20 decks)

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