IPC final exam - lab values, medical records Flashcards

Question 1

Q

Laboratory values are ____ data that complement the clinical impression

SOAP

Answer

A

S: Subjective
O: Objective lab values in this portion
A: Assessment
P: Plan

lab data is objective data

Question 2

Q

Clinical Pearls When Interpreting Lab Data

are normal values the same between labs

do normal values vary based on age, gender, weight and height, what is an example

Laboratory errors can happen due to
technical error, what are some errors that could happen
- math
- specimen
- time
- preservative
- food substance affecting what

what should be done if lab error is expected

Answer

A

Normal values may vary from lab to lab depending on the techniques and reagents used
- MCPHS reference lab values document on Bb (no need to memorize it!)

Normal values may vary depending on the patient’s age, gender, weight, height
- Example: hematocrit/hemoglobin

Laboratory errors can happen due to
technical error
- improper calculation
- inadequate specimen
- incorrect sampling timing
- improper sample preservation
- food substances affecting specimen
- medication interference with lab tests

If laboratory error is suspected, the test should be repeated

Question 3

Q

Lab values present a ____ of what is going on with the ____!

what should you look for

what should you think about

Patient: 140 mEq/L, are they in the normal range for Na+

Answer

A

Lab values present a snapshot of what is going on with the patient!

Look at previous labs
Look at trends

Think about which labs need to be ordered
Think how frequently labs should be ordered

the normal range for Na+:
135-147 mEq/L

The PATIENT is in the normal range!

Question 4

Q

Complete Blood Count (CBC) provides values for:

Harry
Had a
White
Robe but
Molly
Made
Macaroni
Pie

Answer

A

Hemoglobin (Hgb)

Hematocrit (Hct)

White blood cells (WBCs)

Red blood cells (RBCs)

Mean corpuscular volume (MCV)

Mean corpuscular hemoglobin (MCH)

Mean corpuscular hemoglobin concentration (MCHC)

Platelets (Plt)

Question 5

Q

Basic metabolic panel (BMP) or Chem-7 includes:

Suzie
Plays the
Clarinet
But
Bobby plays
Chess really
Good

Answer

A

Sodium (Na+)

Potassium (K+)

Chloride (Cl-)

Bicarbonate (HCO3-)

Blood urea nitrogen (BUN)

Creatinine (SCr)

Glucose (Glu)

this is what the fish bone displays :)

Question 6

Q

Comprehensive metabolic panel (CMP) includes:

Ally

Always

Asks

Awesome

Thoughts

Constantly

Answer

A

BMP or Chem-7

Albumin

Alkaline phosphatase (ALP)

Alanine aminotransferase (ALT)

Aspartate aminotransferase (AST)

Total bilirubin

Calcium

some are liver function test

Question 7

Q

Liver function tests (LFTs) may vary slightly between labs, but generally include what molecules and tests

Always

Asks

And trust

God

Totally

Always

Pray

Intentionally

Answer

A

Aspartate Aminotransferase (AST)

Alanine Aminotransferase (ALT)

Alkaline Phosphatase (ALP)

gamma - Glutamyl Transpeptidase (GGT)

Total bilirubin

Albumin

PT

INR

Question 8

Q

what is Sensitivity of a test

what is a highly sensitive test

what is specificity of a test

what is a highly specific test

what is the ideal test, what are examples

how much Sensitivity & Specificity does the home pregnancy test have and if what

Answer

A

The sensitivity of a test is its ability to designate an individual with a disease as positive.

A highly sensitive test = with few false negative results, = and fewer cases of disease are missed
Example: COVID-19 test: Antigen test versus PCR
- so patient really has the disease

The specificity of a test is its ability to designate an individual who does not have a disease as negative.

A highly specific test = with few false positive results
Example: pregnancy test, rapid strep test

An Ideal test is highly sensitive and highly specific

Home pregnancy tests have 100% sensitivity and specificity if hCG ≥ 25 mIU/mL

Reminder: watch the YouTube video posted on Bb

Question 9

Q

Shorthand Schematics or “Fishbones”

what molecules does it contain

what is the position of each
Hgb at the __ o’clock
Plt at __ o’clock
Hct at __ o’clock
WBC at ___ o’clock

Na, Cl, BUN in the ___ row
K, CO2 (or HCO3-), SCr in ___ row
blood glucose at far ____

Answer

A

and X and fishbones
with:
Hgb
Plt
Hct
WBC

memorize the position

Hgb at the 12 o’clock
Plt at 3 o’clock
Hct at 6 o’clock
WBC at 9 o’clock

Na, Cl, BUN in the top row
K, CO2 (or HCO3-), SCr in bottom row
blood glucose at far right

Question 10

Q

Causes of hypERnatremia:
- high [ ] of ___
- water

what kind of drug can cause this

Causes of hypOnatremia:
- XS of what
- what 3 diseases is associated with this
- what drug can cause this

Answer

A

Causes of hypERnatremia:
- ↑ Na+ intake
- Dehydration:
—-Gastroenteritis
—–Diabetes insipidus (DI)
Drugs:
- Hypertonic saline

Causes of hypOnatremia:
- Excess body water (dilutional hyponatremia),
for example:
- Heart failure
- cirrhosis
- SIADH (fluid overload)

Drugs from Top 200:
Thiazide diuretics:
- chlorthalidone
- HCTZ

Sodium (Na+) - Normal range: 135-147 mEq/L

Question 11

Q

Causes of hypERchloremia:
- water
- DI

Causes of hypOchloremia:
- puke
- SI..
- what drugs can cause this

Answer

A

Causes of hypERchloremia:
- Dehydration
- Diabetes insipidus

Causes of hypOchloremia:
- Prolonged vomiting (lose Cl from stomach)
- SIADH

Drugs from Top 200: Acid suppressants because they decrease HCl production:
H2 blockers:
- famotidine
PPIs:
- omeprazole, pantoprazole, esomeprazole, lansoprazole, dexlansoprazole

CHLORide (Cl-) - Normal range: 95 – 105 mEq/L .

Question 12

Q

Potassium (K+) - Normal range: 3.5 – 5 mEq/L.

Causes of hypERkalemia:
- what organ failure
- water
- massive ____ damages from what
- what about the blood specimen

what Drugs from Top 200 can cause this

Causes of hypOkalemia:
- lose of what

what Drugs from Top 200 can cause this

Answer

A

Causes of hypERkalemia:
- Renal failure
- Dehydration
- Massive cell damage: burns, injuries
- Hemolyzed blood specimen (falsely elevated)

Drugs from Top 200:
- ACEIs: quinapril, Ramipril, benazepril, enalapril, lisinopril
- ARBs: losartan, valsartan, irbesartan
- Potassium-sparing diuretics: Spironolactone

Others drugs: Potassium supplements

Causes of hypOkalemia:
- Severe diarrhea and/or vomiting

Drugs from Top 200:
- Thiazide diuretics: chlorthalidone, HCTZ
- Loop diuretics: furosemide

Question 13

Q

CO2 content or HCO3- Normal range 22 – 28 mEq/L

Causes of increased CO2 content
- metabolic what

Causes of decreased CO2 content
- metabolic what

what Drugs from Top 200 can cause this

CO2 content vs CO2 gas (lungs; acidic)

Answer

A

Causes of increased CO2 content
- Metabolic alkalosis

Causes of decreased CO2 content
- Metabolic acidosis

Drugs:
- salicylate toxicity

Do not confuse CO2 content with CO2 gas
- CO2 content in plasma is mostly HCO3- , regulated by the kidneys, & is a base

CO2 gas is regulated by the lungs & is acidic

Question 14

Q

Blood Urea Nitrogen (BUN) is a marker of renal function. Urea nitrogen is produced in the liver (from protein breakdown)  blood  cleared by kidneys (Normal range 6 – 20 mg/dL)

Causes of ↑ BUN (Azotemia)
- what organ failure
- high what diet
- water
what Drugs from Top 200 can cause this

Causes of ↓ BUN
- what organ failure

Answer

A

Causes of ↑ BUN (Azotemia)
- Acute or chronic renal failure
- High-protein diet
- Dehydration

Drugs that are nephrotoxic:
- From Top 200: NSAIDs ibuprofen

Causes of ↓ BUN
- Liver failure

Question 15

Q

Serum Creatinine (SCr): product of normal breakdown of muscle tissue and is excreted by glomerular filtration in the kidneys = marker of renal function (Normal range: 0.6 – 1.2 mg/dL)

Causes of increased SCr
- what organ dysfunction
- water
- workout

What drugs can cause this

Causes of decreased SCr
- muscle

Answer

A

Causes of increased SCr:
- Renal dysfunction
- Dehydration
- Vigorous exercise (just like for increase Hgb!)

Drugs: nephrotoxic drugs
- from Top 200:
Acyclovir, NSAIDs, cyclosporine

Causes of decreased SCr
Inactive elderly (low muscle mass)

Question 16

Q

Glucose - Normal range 70 – 99 mg/dL

Causes of hypERglycemia
- DM
- what kind of infection
What drugs can cause this

Causes of hypOglycemia
- missing what
What drugs can cause this

Answer

A

Causes of hypERglycemia
- Diabetes mellitus (DM)
- Sepsis - blood infection

Drugs from Top 200:
- Corticosteroids: prednisone, prednisolone, methylprednisolone
- Atypical antipsychotics: aripiprazole, risperidone, quetiapine, olanzapine

Causes of hypOglycemia
Missing a meal

Drugs from Top 200:
- sulfonylureas: glimepiride, glipizide, glyburide
- Insulin overdose

Question 17

Q

Calcium (Ca): 98-99% in skeletal bones & teeth, remainder in blood, muscles, other tissues (Total Ca normal range: 8.5 – 10.5 mg/dL)

In the blood how much calcium is in an ionized “free” state what does it do

In the blood how much calcium is bound to proteins (albumin)

what can occur due to low albumin levels

what kind of Ca2+ is usually reported in labs

Answer

A

In the blood
≈ half of the calcium is in an ionized “free” state  exerts physiologic functions

≈ half of the calcium is bound to proteins (albumin)

Pseudohypocalcemia can occur due to low albumin levels
- calculate corrected calcium when albumin < 4 g/dL
total Ca is usually reported in labs

Corrected calcium = reported serum calcium + 0.8 (4 – patient’s albumin) - for therapeutics

Question 18

Q

Some causes of Calcium imbalance

Causes of hypERcalcemia

Drugs:
- what drug toxicity
- from top 200

Causes of hypOcalcemia
- what deficiency
- what disease

Drugs from Top 200:

Answer

A

Causes of hypERcalcemia
- Malignancies

Drugs:
- Vitamin D toxicity
- From Top 200: Thiazides: HCTZ, chlorthalidone

Causes of hypOcalcemia
- Vitamin D deficiency
- Renal disease

Drugs from Top 200:
- Loop diuretics: furosemide

Question 19

Q

SIADH - what is it referring to

DI - is Na+ high or low

Answer

A

SIADH - soaked inside
In DI, sodium is high

Question 20

Q

what % are RBC, WBCs/Plt, Plasma in spun down sample

RBCs are about ___%

WBCs and Plt about __%

plasma about ___%

what does the plasma have

Answer

A

RBCs are about 40-45%

WBCs and Plt about 5%

plasma about 55%

plasma has Chem-7

Question 21

Q

sodium and chloride relationship

Answer

A

go up together and go down together

Question 22

Q

calcium & phosphorus relationship

Answer

A

more calcium = less phosphate

less calcium = more phosphate

Question 23

Q

Phosphate (PO4-) - Normal range: 2.5 – 4.5 mg/dL

Causes of hypERphosphatemia
- what organ dysfunction
- increased what intake

what drugs cause this

Causes of hypOphosphatemia
- is the nutrition good

what drugs cause this

Answer

A

Causes of hypERphosphatemia
- Renal dysfunction
- Increased phosphate intake

Drugs:
- Increased vitamin D intake
- Laxatives

Causes of hypOphosphatemia
- Malnutrition

Drugs:
- Overuse of aluminum-containing antacids
- Overuse of calcium-containing antacids

Question 24

Q

Magnesium (Mg) - Normal range 1.5 – 2.4 mEq/L

Causes of hypERmagnesemia
- what is the one cause

What drugs cause hypermagnesmia

Causes of hypOmagnesemia
- rectal
- food
- poor

What drugs cause this

Answer

A

Causes of hypERmagnesemia
Renal failure

Drugs:
- Magnesium supplements
- Magnesium-containing antacids
- Magnesium-containing laxatives

Causes of hypOmagnesemia
- Diarrhea
- Vomiting
- Malabsorption

Drugs from Top 200:
- furosemide, HCTZ, chlorthiazide
- PPIs (example: omeprazole, pantoprazole, esomeprazole, lansoprazole, dexlansoprazole)

Question 25

Q

Albumin: a predominant serum-binding protein that transports various substances including medications. It is synthesized only in the liver(Normal range: 3.5 – 5 g/dL)

Causes of hypOalbuminemia
- cirrhosis in what organ
- is the nutrition good
- syndrome where

Answer

A

Causes of hypOalbuminemia
- Liver cirrhosis(defective synthesis)

Malnutrition (decreased synthesis)
Nephrotic syndrome (increased loss)

Question 26

Q

One consequence of hypoalbuminemia

Answer

A

One consequence of hypoalbuminemia is that drugs that are usually protein-bound become free in the plasma, allowing for higher drug levels, more rapid hepatic metabolism, or both

Question 27

Q

Complete Blood Count (CBC) Complete Blood Count (CBC)

Answer

A

WBC
Hgb
Hct
RBC
Reticulocytes
Red Blood Cells Indices (MCV, MCH, MCHC), Platelets

Question 28

Q

White Blood Cell (WBC) count = leukocyte count: total number of WBCs in a given volume of blood (Normal range: 3.2 – 11.3 x 103 cells/mm3)

never let monkeys eat bananas- what does each first letter indicate

Causes of increased WBCs/Leukocytosis
- what does left shift mean
- what else could be going on

drugs

Causes of decreased WBCs/Leukopenia
- what kind of therapy

Answer

A

never let monkeys eat bananas
- neutrophils
- lymphocytes
- monocytes
- eosinophils
- basophils

Causes of increased WBCs/Leukocytosis
- Infection
- Leukemia
“left shift” refers to infection or leukemia, increase in bands (immature neutrophils)
- Trauma, stress

Drugs from Top 200: corticosteroids: - prednisone, prednisolone, methylprednisolone

Causes of decreased WBCs/Leukopenia
Drugs:
- Chemotherapy

Question 29

Q

Red Blood Cell (RBC) count = Erythrocyte Count: Actual amount of RBCs per unit of blood (Normal range: M: 4.3 – 5.9 x 106 cells/microliter, F: 3.5 – 5 x 106 cells/microliter)

how many Hgb does a single erythrocyte have

Answer

A

A single erythrocyte can contain 300 million hemoglobin (Hgb) molecules, therefore, conditions that affect Hgb count will affect RBC count

Question 30

Q

Hemoglobin (Hgb) is the oxygen-carrying compound found in RBCs (Normal range for adults: M: 14 – 18 g/dL, F: 12 – 16 g/dL)

Causes of increased Hgb:
- smoking
- smokers
- gym
- mountain
- a type of cancer

Causes of decreased Hgb:
- are there enough blood cells
- is there blood retained
- having a baby?

drugs
- glucophage
- ibuprofen, naproxen pharm category

Answer

A

Causes of increased Hgb:
- COPD
- Chronic smokers
- Regular vigorous exercise
- Living at high altitude
- Polycythemia vera: a cancer that produces a lot of RBCs

Causes of decreased Hgb:
- Anemia
- Blood loss
- Pregnancy

Drugs from Top 200:
- Metformin
- NSAIDs (may cause bleeding): ibuprofen, naproxen, meloxicam, diclofenac, celecoxib

Question 31

Q

Hematocrit (Hct): percentage volume of blood occupied by RBCs.AKA, packed cell volume (PCV) (Normal range: M: 39-49 %, F: 33-43 %)

Causes of increased Hct:
- same as what
- water

Causes of decreased Hct:

what is the rule of thumb

Answer

A

Causes of increased Hct:
Same as hemoglobin
Dehydration

Causes of decreased Hct:
Same as hemoglobin

Rule of thumb: Hct value = 3 X Hgb value

Question 32

Q

normal

anemia

polycythemia

dehydration

Answer

A

normal = 45%

anemia = 30%

polycythemia = 70%, produce lots of RBCs due to cancer

dehydration = 70%, less plasma

so measure Hgb instead of Hct

Question 33

Q

Platelets: critical for blood clot formation(Normal range: 150, 000 – 450, 000 cells/microliter)

Causes of ↑ Platelets (thrombocytosis)
- tumor
- which organ is removed
- chronic ___ disorders
- a type of cancer

Causes of ↓ Platelets (thrombocytopenia)
- what kind of disorders
- ITP
- what kind of therapy and is there radiation

what drugs can cause this

Answer

A

Causes of ↑ Platelets (thrombocytosis)
- Malignancy
- Splenectomy
- Chronic inflammatory disorders
- Polycythemia vera

Causes of ↓ Platelets (thrombocytopenia)
- Autoimmune disorders:
- Idiopathic thrombocytopenia purpura (ITP)
- Chemotherapy, radiation

Drugs from Top 200:
- Valproic acid

Question 34

Q

what are the 2 Coagulation Tests

Question 35

Q

Prothrombin Time (PT) is the time it takes the blood to clot; PT = 10 – 13 seconds in patients not on anticoagulants

Causes of increased PT:
- what organ disease
- what vitamin defificny
- what factors deficiency

what drugs cause this

what does the liver manufacture

Answer

A

Causes of increased PT:
- Liver disease
- Vitamin K deficiency
- Clotting factors deficiency

Drugs: anticoagulants
- Example Top 200: warfarin, rivaroxaban

liver manufactures proteins and clotting factors

Question 36

Q

PT may vary due to the thromboplastin used

Answer

A

blood sample with citrate - binds calcium

centrifuge

discard blood cells

get plasma-calcium, thromboplastin includes tissue factor and phospholipids

fibrin clot

Question 37

Q

International Normalized Ratio (INR) is used to standardize PT; adjusts PT ratio based on sensitivity of thromboplastin used to perform test

what kind of med is it used to monitor

what does the INR range depend on

what is the normal INR

Answer

A

Used to monitor warfarin therapy

The desired INR range depends on the indication of warfarin therapy
- Target INR = 2-3 or 2.5-3.5

Normal INR (for patients not taking warfarin) = 1

warfarin: “alright, alright break it up, you guys!” a blood thinner

Question 38

Q

Immunologic Tests

Question 39

Q

Erythrocyte Sedimentation Rate (ESR) measures rate of erythrocyte settlement in anticoagulated blood

what raises the ESR

is it a specific diagnostic test

what is it used to support

Answer

A

Infections or inflammatory disorders = erythrocytes settle more quickly = ↑ ESR

Nonspecific diagnostic test

Used to support a diagnosis or monitor progress of inflammation or infection

Question 40

Q

Gastrointestinal Tests

Answer

A

ALT
AST
ALP
GGT
Bilirubin
Amylase
Lipase

Question 41

Q

Alanine Aminotransferase (ALT): enzyme present in high concentrations in the liver tissue (Normal range 0 – 35 International Units/L)

Causes of high ALT:
- what organ disease

what drugs cause this
- for HTN
- Ph
- toxicity to what drug

does the liver produce more or less ALT or AST

Answer

A

↑ > 3 x upper limit  SIGNIFICANT
Specific marker of liver disease

Causes of high ALT:
- Liver disease

Drugs from Top 200:
- HMG-CoA reductase inhibitors (statins): atorvastatin, lovastatin, pravastatin, simvastatin
- Phenytoin
- APAP toxicity

liver produces more ALT than AST

Question 42

Q

Aspartate Aminotransferase (AST): an enzyme in the liver, heart, kidney, pancreas, lungs, and skeletal muscles (Normal range 0 – 35 International Units/L)

what causes it to elevate

is it more or less of a specific marker for liver disease

what would indicate liver disease

what drugs
- toxcity to what drug

Answer

A

Injury to these tissues  higher AST

Less specific marker of liver disease than ALT

AST : ALT > 2:1 (more than twice) means alcoholic liver disease

Drugs:
- APAP toxicity

Question 43

Q

Cardiac Tests

Answer

A

CK, CK-MB, Troponin, CRP

Question 44

Q

Creatine Kinase (CK) may be fractionated to isoenzymes

Causes of elevated total CK:
- is there injury
- was there an operation
- Rhabdomyolysis (lol)

what drugs cause this
for HTN
for hyperlipidemia

Causes of elevated CK-MB:
- heart attack
- what time does it begin to rise, when can you not measure it
- when does it peak
- when does it return to normal

Answer

A

Causes of elevated total CK:
- Trauma
- Surgery
- Rhabdomyolysis

Drugs from Top 200:
- Statins
- Fibrates: fenofibrate

Causes of elevated CK-MB:
- Acute myocardial infarction (AMI)
- Begins to rise in 4 – 8 hours, cannot measure before 4 hours
- Peaks in 12 – 24 hours
- Returns to normal in 2 – 3 days

Question 45

Q

Troponins
- where are they found and when is it released
- begins to rise after how many hours
- what are they sensitive markers for

C-reactive protein (CRP)
- where is it produced
- what is it a diagnosis of
- is it specific or unique it one disease
- what 2 things can it help monitor

Answer

A

Troponins are proteins found in cardiac muscles, released during cardiac injury
- Begin to rise in 4 hours
- Sensitive markers of cardiac injury

C-reactive protein (CRP) is produced in the liver
- Diagnosis of inflammatory conditions like rheumatoid arthritis
- Not specific; not unique to one disease
- Can help monitor disease progress and flares

Question 46

Q

Which of the following laboratory tests would you monitor to assess a patient’s diabetes management?

A. Sodium
B. Potassium
C. Glucose
D. Chloride

Answer

A

C. Glucose

Question 47

Q

Which of the following medications may cause an increase in creatine kinase (CK)?
A. Simvastatin
B. Lisinopril
C. Hydrochlorothiazide
D. Furosemide

Answer

A

A. Simvastatin

lisinopril raises K+ levels

HCTZ would cause hyponatremia & hypokalemia

furosemide would cause hypokalemia & hypocalcemia

Question 48

Q

where is Cl in the fishbone?

Answer

A

up, middle box

start with the +
then -
then kidney

then glucose at the far right

Question 49

Q

Which of the following electrolyte imbalances may result from a patient being dehydrated?
A. Hypernatremia
B. Hyperkalemia
C. Hyperchloremia
D. All of the above

Answer

A

D. All of the above

because all of the ions will be depleted

Question 50

Q

You are on APPE rotation with the ICU team. When preparing for rounds, you note that there was a new admission last night—patient AB who was struck by a car. Which laboratory tests would you expect to see in this patient’s chart?
A. AST/ALT
B. Hgb/Hct
C. ESR

Answer

A

worry about their bleeding/bleed
B. Hgb/Hct
tells if you have bleeding

AST/ALT tells about liver function

ESR tells also check for inflammation or infection in your body. This is an immunological test

Question 51

Q

You are a student on your APPE rotation and asked to recommend a dose for a medication that is adjusted for renal function. Which laboratory value specific to your patient do you need to know?
A. Glucose
B. Serum creatinine
C. Sodium
D. AST

Answer

A

B. Serum creatinine
with poor function, should be elevated

if low, then could be elderly where they have low muscle mass

Question 52

Q

Infections can result in an elevated WBC count with a left-shift
A. True
B. False

Answer

A

true

“Left Shift”
Increase in bands (immature neutrophils) due to:
- Infection
- Leukemia

Question 53

Q

What is a Medical Record?

Answer

A

According to Stedman’s Medical Dictionary:
A chronologically written account that includes a patient’s initial complaint(s) and medical history, physical findings, results of diagnostic tests and procedures, any therapeutic medicines or procedures, and subsequent developments during the course of the illness.”

Legal set of documents that are a record of a patient’s private medical information

AKA “The Chart”
- legal set of documents

Question 54

Q

What is a Medical Record?

Answer

A

Historically: medical records were actual paper in folders kept in physician’s office

Most hospitals/institutions/physician offices now utilize:
- Electronic medical records (EMR) or also called Electronic health records (EHR)

Personal health records (PHR)- maintained by patient

Question 55

Q

Why use an Electronic Medical Record?

Answer

A

Central point for all medical data for a patient
- Eliminate the majority of paper documentation
- Communication across all healthcare institutions

Even though this concept sounds like each patient would only need 1 EMR, often a patient has
- 1 for in-patient
- 1 for ambulatory setting since there are different requirements/sections of a medical record depending on the location of the care being provided (more to come on this)

Question 56

Q

Who Can Use/View a Medical Record?

Answer

A

Health care providers
- Able to view and use the chart for the patients they are responsible for
- ILLEGAL to access a patient’s chart if not currently under their care, protected by HIPAA

Patient
- Can view and in some cases, add/change their own chart (more to come on this)
- cannot access chart

Question 57

Q

Where is a Medical Record Located?

how do you access it
-what must you obtain
- may have limited access depending on what
- with appropriate credentials, what can you view

Answer

A

Must obtain a username and password for specific EMR

May have limited access depending on your credentials

With appropriate credentials, able to view the EMR from anywhere there is a computer (even off-site)

Question 58

Q

Components of In-patient Medical Record

Answer

A

History and physical (H&P)
- Emergency Department notes (possibly)

Progress notes - how are they doing, every 24 hours

Procedure reports - stitching wound, setting a broken leg, catheter, IV, etc, anything is done to the patient

Laboratory and imaging data

Consults - with other specialties

Orders - nutrition,

Allergies - meds, environmental

Medication administration record (MAR)/home medication list - documents meds and when to take them

Social work/case management notes

Question 59

Q

Components of Ambulatory Medical Record

Answer

A

Demographics - family, surgical

Allergies

Problem list - what are all of their chronic conditions

Social, family, and surgical histories

Vitals/laboratory values

Immunization records

Notes/Documentation on previous visits, were you with me or the provider that I’m working with

“Tasks” or referrals to other healthcare providers
- Consult notes sent from other healthcare providers

Question 60

Q

What is a Personal Health Record?

what is the definition

what is it managed by

what can it include information from who

what can it help patients do

are they separate or can they replace the legal record of any healthcare provider

what are they distinct from

what does pmhx and osa mean

Answer

A

Definition: An electronic application used by patients to maintain and manage their health information in a private, secure, and confidential environment

Managed by patients

Can include information from a variety of sources, including healthcare providers and patients themselves

Can help patients securely and confidentially store and monitor health information, such as diet plans or data from home monitoring systems, as well as patient contact information, diagnosis lists, medication lists, allergy lists, immunization histories, and much more

Separate from, and do not replace, the legal record of any health care provider

Are distinct from portals that simply allow patients to view provider information or communicate with providers

pmhx: past medical history
OSA: obstructive sleep apnea

C = critical

Question 61

Q

What is the Difference Between a PHR and EMR?

Answer

A

EMR: Accessed and utilized by health care providers only. Owned and maintained by doctors’ offices, hospitals, or health insurance plans.

PHR: Record controlled by the patient and may use information from a wide array of sources (providers and patients)

Important: a PHR is separate from the legal EMR

Question 62

Q

Two Types of PHR are:

Standalone PHR’s:
- patients provde info based on what
- where is this stored
- what can patients determine

Tethered/Connected PHR’s:
- what is.it linked to
- how can patients access their own health records
- kept condifental through what act
- what type of portal is this

Example of Personal Health Record
- what app on iphone, what does it include

Answer

A

Standalone PHRs:
- Patients provide information based on their memory or records
- Stored on the patient’s computer or internet
- Patients can determine if they want to share this with providers or others.

Tethered/Connected PHR’s:
- Linked to a specific healthcare organization’s electronic health record (EHR) system or to a health plan’s information system
- Patients can access their own records through a secure portal and see, for example, the trend of their lab results over the last year, their immunization history, or due dates for screenings
- Kept confidential through the HIPAA privacy act
- “Patient Portal”

Example of Personal Health Record:
Health app for iPhones
- Includes Medical ID: makes critical information available via lock screen for use by first responders in emergency

Question 63

Q

Fully Transparent Medical Records via PHR

Answer

A

Patients can access doctor visit notes:
- Summary of conversation
- Symptoms patient described
- Doctor’s findings from physical exam

Patients have legal rights to medical records, but difficult and potentially costly to obtain

Question 64

Q

Fully Transparent Medical Records via PHR goals

Answer

A

Goals:
- Improve communication between patients and providers
- Improve medication adherence

Answer 63

A

storage - EMR is better
legibility - EMR is better
access - EMR is better
security - equal for EMR (could be cyber security, or someone could look over your shoulder) & paper (someone could break in, can be easy to print out and leave somewhere
cost - EMR (more expensive up front, long process, training people, working out bugs) and paper (is expensive)

Answer 64

A

easy to share info. between offices
easier to track

Answer 65

A

EHR faster to type in
10-13 pieces of paper for each patent and physician sees 50-99 patients in a week so it wil cut down a lot
savings: 100B
4.5M ambulatory visits related to adverse drug events occur annually in the U.S

Answer 66

A

Sample software-
inpatient: epic or Cerner
ambulatory: Allscripts or Athena health

Data presented
inpatient: episode based
ambulatory: longitudinal

Versatility
inpatient: versatile due to all consultants writing into the same chart
ambulatory: less versatile; very specific to that particular practice

Ordering systems
inpatient: Computerized Physician Order Entry (CPOE)
Can only order medications from inpatient pharmacy
ambulatory: Require access to order medications from various pharmacies

Laboratory information

Consultation vs. referral

Answer 67

A

A- EMR
- do not have to be in a location or someone certain

Answer 68

A

B
Lab data

Answer 69

A

D
Consult notes

Answer 70

A

being able to have patient-provider communication

med refills

improve patient engagement

coordinate info. from multiple providers

ensure important info. is available for an emergency

encourage family health management

Answer 71

A

Benefits:
- more education about their health
- better understanding of their own health status
- will prevent forgetting directions or info/reduce med errors and increase adherence

Risks:
- malpractice if the physician did something wrong
- may not know med abbreviations
- may not fully understand what they read and could be hurt :( could cause confusion and miscommunication

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IPC final exam - lab values, medical records Flashcards

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