Midterm Flashcards
Electronic health record?
- Available electronically
- Recorded electronically by multiple healthcare members
- Single file that can be accessed
Difference of EMR and EHR?
An EMR is available to only 1 facility. EHR available to multiple.
Longitudinal health record contains?
- Documentation from multiple providers
- Stores patient info as long as received care
- It’s not static; changing with patient care
EHR does not include what type of info?
Security info
What is true about the interoperability?
The higher the level the greater the capability of interoperation.
Difference between level 2 and 3 interoperability?
- Level 2 data format is common, level 3 data is shared
- Level 3 is higher level interoperability
Syntactic Interoperability?
- There’s common data between the 2 systems
- They have a common technical foundation
- The data cannot be interrupted
What is not true about Interoperability?
It is designed specifically for healthcare.
A computer protocol is?
A standard method of communication between 2 computers.
What is the ONC role?
To improve healthcare and health for all Americans through use of info and technology.
Nationwide Health Information Network (NwHIN)
A set of standards, services, and policies that make it possible to securely exchange health info over internet.
HITECH act marks significant achievement for healthcare because:
- Billions of dollars for healthcare info technology
- Provides incentives for physicians and hospitals
- Established national health info technology research center
____________ are not eligible providers for medicare.
Doctors of Psychiatry
_________________ are not eligible providers for medicaid.
Doctors of Optometry.
One way the govt encouraged implementation of EHRs?
By reducing reimbursement rates gradually for physicians.
Meaningful use?
Set of standards for using EHRs defined by CMS.
What is NOT true about meaningful use?
Criteria are to be implemented in all facilities at the same time.
What are the benefits of an EHR?
- Improved documentation
- Improved access
- Faster communication
What’s the difference between RHIT and RHIA?
RHIA - Bachelors
RHIT - Associates
Challenge of EHRs present opportunities in which main areas?
- Privacy and security
- Training
What may NOT be considered a healthcare facility according to US National Library of Medicine?
Insurance company
1 of the greatest accomplishments of the ACS is?
-Established the minimum standards for hospitals
Media used to store med records over the years?
- Paper
- Microfilm
- Optical Scanning
A health record includes?
- Past medical condition
- Present health info
- Treatments provided
What is NOT an example of legal data?
Emergency contact info
Who primarily uses the core data set developed by the AHIMA?
Physician offices
Health Record format can:
Vary but needs to be consistent.
Patients admitted to an acute care setting or long term hospital are?
Inpatients
What is Source-oriented format (SOR)?
Going from one source to another.
The Dr. removed liver tissue and sent to the lab for analysis. He completed a:
Pathology
Consent is signed by the patient, a discharge summary is signed by ___________.
The physician
A typical document found in an ambulatory care record but NOT in a hospital?
-Problem list
Referral
Document that gives patient permission to be seen by another provider.
What is NOT considered general guidelines for documentation?
-Ensuring there is no corrected documentation.
A wrong entry can be changed by:
Writing an addendum documented in an EHR.
____________ is NOT an accreditation?
American Health Information Management Association (AHIMA)
Example of challenges that may be associated with EHRs?
-Training users may be difficult
Which is NOT true about a well designed EHR?
Physicians love it because they no longer have to sign documents.
Example of clinical input.
Diagnosis code
Which is NOT an example of Unstructured data?
Gender
Searching for and examining data to organize into useful patterns and trends is?
Data mining
Manual data collection is accomplished by?
Staff directly typing it in.
Dr. Lee notes patient complains of abdominal pain, vital signs, etc. What document will this info be found?
History and physical
Physical exam does NOT include?
Allergies
Patient is complaining of chest pain. What type of info is this?
Subjective
Nurse orders antibiotics. Which part of history and physical is this documented?
Treatment plan
