Midterm #1

Question 1

What are the most used (HIS) in Canada?

Answer 1

Meditech, Epic and Cerner

Question 2

What is (HIS) and what is the purpose of it?

Answer 2

A hospital information system, it is designed to manage numerous aspects of health data in a health care facility.

Question 3

What are (HIS) purposes?

Answer 3

• Order entry
• Clinical documentation
• Communication
• Billing
• Medication Log
• Generating Reports
• Payroll

Question 4

What is a health record?

Answer 4

Any documentation relating to a patient.

Question 5

What is a record?

Answer 5

A record refers to a single document, such as a doctor’s note or and assessment or a lab report.

Question 6

What is a chart?

Answer 6

A chart is the collection or file folder of such documents.

Question 7

What is an EMR?

Answer 7

Electronic medical record

It is a patient record maintained by a physician overtime - essentially a patient chart, but in electronic form.

Question 8

What is an EHR?

Answer 8

Electronic Health Record

It is a compilation of a patient’s health data from multiple sources.

Question 9

What are the components of an electronic record?

Answer 9

• Patient profile
• Progress notes
• Physical assessments
• Laboratory results report
• Consent forms

Question 10

What is the Life Cycle of a Record?

Answer 10

Creation - of a patient’s record
Maintenance - via a filing or indexing system
Provision - of policies and level of access to patient records
Disposition - and archiving of records

Question 11

What is the cycle of a health record?

Answer 11

• Retrieval of information
• Storage
• Management of information

Question 12

What does a complete EMR include?

Answer 12

• Basic demographics
• Medical history
• Social and family history
• Functional inquiry
• History of present illness
• Diagnosis
• Treatments and medications

Question 13

What does local solution mean?

Answer 13

Where the records are stored on a local hard drive. The back-up and security of the health information is the clinics responsibility.

Question 14

What does central solution mean?

Answer 14

Where the information is hosted remotely by an application service provider. The provider retrieves/stores off-site. The vendor is responsible for the back-up security.

Question 15

All EMR systems must offer what?

Answer 15

• An audit trail
• The ability to allow providers to sign off on entries using electronic signatures
• The means to regularly save and back up data
• Effective protocols for information recovery

Question 16

When are charts considered inactive?

Answer 16

When a provider has not seen a patient for a certain period of time but is not sure whether the patient has left the practice.

Question 17

When are charts considered closed?

Answer 17

When patients leave the practice for any reason (including death).

Question 18

What is the Privacy Act?

Answer 18

The privacy act concerns departments and agencies within the federal government in terms of outlining obligations, rules and policies related to collection, disclosure and use of personal information.

Question 19

What does (PIPEDA) stand for?

Answer 19

The Personal Information Protection and Electronic Documents Act

Question 20

What is the (PIPEDA)?

Answer 20

PIPEDA outlines how organizations within the private sector (including all
health-care agencies, drug companies, offices and clinics) can collect, use,
or disclose personal information.

Question 21

What are the 10 principles of PIPEDA?

Answer 21

• Accounting
• Identifying purposes
• Consent
• Limits to information
• Limits to use of information
• Accuracy
• Safeguards
• Openness
• Individual access
• Challenging compliance

Question 22

Health records have a dual ownership. Who are the owners of the health record?

Question 23

What are the different types of Admission?

Answer 23

• Pre booked or Elective admission
• Obstetrical

Question 24

What are Pre-booked or Elective admissions?

Answer 24

• They occur when the admission is scheduled ahead of time.
• An elective admission can also be for extensive and/or invasive diagnostic tests.
• Most of the paperwork is completed ahead of time.

Question 25

Elective admissions are primarily for what?

Answer 25

Surgical procedures ( cardiac bypass surgery, hernia, hip replacement)

Question 26

What are emergency admissions?

Answer 26

• Usually occur when a patient is admitted through the ED.
• Patients presenting in the ED are triaged according to their condition.
• Appropriate assessments are made including diagnostic tests.

Question 27

Explain Obstetrical Admission

Answer 27

• Obstetrical patients are triaged when they are in suspected labour and admitted when labour is established/confirmed.
• Once born, a baby is admitted separately.
• Obstetrical emergencies are admitted through the ED or sent in by their physician.

Question 28

What does a basic medical chart include?

Answer 28

• The admission/face sheet
• Admission interview/assessment
• Doctor’s orders
• Medications administration record
• Vital Signs (in graph format)
• eKardex
• Multidisciplinary notes
• Progress notes
• Consultation and other dictated reports
• Lab and diagnostic imaging reports
• A fluid balance graph
• IV therapy documentation

Question 29

What does a surgical chart include?

Answer 29

The same as a basic medical chart but it also contains:

• pre-anesthetic questionnaire
• anesthetic record
• OR check list
• surgical consent
• OR report
• pathology report (dictated)

Question 30

What does AMA mean?

Answer 30

Against medical advice

If a patient insists on leaving the hospital without a
physician’s order, they must sign a release form
stating that they are leaving without permission.