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MT 637: HIS > MT 637 UNIT 6 > Flashcards

MT 637 UNIT 6 Flashcards

1
Q

Why should we encourage the healthcare practitioners to move to an electronic system?

A

We should focus on encouraging them to:
1. Improve the accuracy and quality of data recorded in a health record
2. Enhance healthcare practitioners’ access to a patient’s healthcare information
3. Improve the quality of care
4. Improve the efficiency of the health record service
5. Contain healthcare costs

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2
Q

“An electronic health record is not a simple replacement of the paper record.”

A

A paperless environment will come.

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3
Q

“Current problems identified in healthcare documentation, as well as privacy and confidentiality issues must be addressed, and quality control measures introduced before a successful change can be implemented.”

A

A paperless environment will come.

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4
Q

Collection of computer-stored images of traditional health record documents
- Scanned into a computer
- Stored on optical disks

A

Automated Health Records (AHR)

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5
Q

What year focused on storing on optical disks; which addressed access, space, control problems

A

1990

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6
Q

What year focused on scanning documents alone

A

1990

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7
Q

Describe automated systems based on document imaging or systems

A

Electronic Medical Record (EMR)

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8
Q

Developed within a medical practice or health center

A

Electronic Medical Record (EMR)

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9
Q

EMR Includes:

A

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

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10
Q

Collection of health information for one patient linked by a patient identifier
○ Medical alerts
○ Medication orders
○ Integrated data on a patient’s registration
○ Admission and financial details
○ Recording information from nurses, laboratory, radiology, and pharmacy

A

Computer-based Patient Record (CPR)

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11
Q

What year was CPR introduced?

A

1990s

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12
Q

Contains all personal health information belonging to an individual

A

Electronic Health Record (EHR)

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13
Q

Entered and accessed electronically by healthcare providers over the person’s lifetime

A

Electronic Health Record (EHR)

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14
Q

Extends beyond acute inpatient situations

A

Electronic Health Record (EHR)

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15
Q

EHR is also called

A

longitudinal health record

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16
Q

Includes dimension of time

Allows inclusion of information across providers which will evolve into lifetime record

A

EHR

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17
Q

TRUE/FALSE: The EHR should reflect the entire health history of an individual across his or her lifetime including data from multiple providers from a variety of healthcare settings.

A

True

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18
Q

Digital version of paper charts

A

Electronic Medical Record (EMR)

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19
Q

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

A

Electronic Medical Record (EMR)

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20
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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21
Q

Focus on the total health of the patient
○ Going beyond standard clinical data collected
○ Share information with other health care providers and organizations
○ Decision-support capabilities

A

Electronic Health Record (EHR)

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22
Q

TRUE/FALSE: EHR is present in the PH.

A

False

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23
Q

An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff in one healthcare organization

A

Electronic Medical Record

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24
Q

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization

A

Electronic Health Record

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25
Q

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual

A

Personal Health Record

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26
Q

What are the major issues?

A

Unique patient identification is a major issue that should be addressed before moving forward to automation - Control Problems

Accurate patient identification is the backbone of an effective and efficient health record system, whether manual or electronic - Typographical Errors

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27
Q

Other possible issues?

A
  1. Clinical Data Entry Issues & Lack of Standard Terminology
  2. Resistance to Computer Technology and Lack of Computer Literacy
  3. Strong Resistance to Change by many Healthcare Providers
  4. High Cost of Computers & Computer Systems & Funding Limitations
  5. Concern by Providers as to Whether Information will be Available on Request
  6. Concerns about privacy, confidentiality, and the quality & accuracy of electronically generated information
  7. Quality of electronic healthcare information & accuracy of data entries
  8. Lack of staff with adequate knowledge of disease classification systems
  9. Manpower issues
  10. Environmental issues
  11. Involvement of Clinicians & Hospital Administrators
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28
Q

What are the safeguards which may 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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29
Q

Simple Electronic Record System

A

➢ Patient ID Registration ATS
➢ Lab/haem/Path/Bio-Chem/Etc. Radiology
➢ Scanned documents / previous medical records
➢ Disease classification and indexing
➢ Clinical data treatment orders/results; OPD visits

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30
Q

Functions of an EHR System as Defined by the IOM

Core Functions or Other Functions?

Health information and data: includes medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results

A

Core

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31
Q

Functions of an EHR System as Defined by the IOM

Core Functions or Other Functions?

Results management: manages all types of results (for example, laboratory test results, radiology procedure results) electronically

A

Core

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32
Q

Functions of an EHR System as Defined by the IOM

Core Functions or Other Functions?

Order entry and support: incorporates use of computerized provider entry, particularly in ordering medications

A

Core

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33
Q

Functions of an EHR System as Defined by the IOM

Core Functions or Other Functions?

Decision support:
employes computerized clinical decision-support capabilities such as reminders, alerts, and computer-assisted diagnosing

A

Core

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34
Q

Functions of an EHR System as Defined by the IOM

Core Functions or Other Functions?

Electronic communication and connectivity: enables those involved in patient care to communicate effectively with each other and with the patient; technologies to facilitate communication and connectivity may include e-mail, web messaging, and telemedicine

A

Other

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35
Q

Functions of an EHR System as Defined by the IOM

Core Functions or Other Functions?

Patient support: includes everything from patient education materials to home monitoring to telehealth

A

Other

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36
Q

Functions of an EHR System as Defined by the IOM

Core Functions or Other Functions?

Administrative processes:
facilities and simplifies such processes as scheduling, prior authorizations, insurance verification; may also employ decision-support tools to identify eligible patient patients for clinical trials or chronic diseases management programs

A

Other

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37
Q

Functions of an EHR System as Defined by the IOM

Core Functions or Other Functions?

Reporting and population health management: establishes standardized terminology and data formats for public and private sector reporting requirements

A

Other

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38
Q

medical and nursing diagnoses

A

Health information and data

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39
Q

medication list

A

Health information and data

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40
Q

allergies

A

Health information and data

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41
Q

demographics

A

Health information and data

42
Q

clinical narratives

A

Health information and data

43
Q

laboratory test results

A

Results Management

44
Q

manages all types of results electronically

A

Results management

45
Q

laboratory test results, radiology procedure results

A

Results management

46
Q

incorporates use of computerized provider entry, particularly in ordering medications

A

Order entry and support

47
Q

employes computerized clinical decision-support capabilities such as reminders, alerts, and computer-assisted diagnosing

A

Decision Support

48
Q

enables those involved in patient care to communicate effectively with each other and with the patient; technologies to facilitate communication and connectivity

A

Electronic communication and connectivity

49
Q

e-mail, web messaging, and telemedicine

A

Electronic communication and connectivity

50
Q

includes everything from patient education materials to home monitoring to telehealth

A

Patient Support

51
Q

facilities and simplifies such processes as scheduling, prior authorizations, insurance verification; may also employ decision-support tools to identify eligible patient patients for clinical trials or chronic diseases management programs

A

Administrative processes

52
Q

establishes standardized terminology and data formats for public and private sector reporting requirements

A

Reporting and population health management

53
Q

Benefits of the Use of 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
54
Q

Secure website through which patients can electronically access their medical records

A

Patient Portal

55
Q

Patient portal enables users to

A

○ Complete forms online
○ Schedule appointments
○ Communicate with providers
○ Request refills on prescriptions
○ Review test results
○ Pay bill

56
Q

Key distinguishing characteristic of fully functional EHRs

A

Clinical Decision Support

57
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

58
Q

Barriers to Adoption:

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

A

Financial

59
Q

Barriers to Adoption

Use and acceptance of changes in workflow

A

Organizational/Behavioral

60
Q

Barriers to Adoption:

Work and technology needed to build system interfaces

A

Technical

61
Q

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

AHIMA 2016

A

Personal Health Records (PHR)

62
Q

Not managed by a healthcare organization or provider and does not constitute a legal document of care but contains all pertinent health care information

A

Personal Health Records (PHR)

63
Q

“…effective tool enabling patients to be active members of their own health care teams.”

A

Personal Health Records (PHR)

64
Q

AHIMA stands for

A

American Health Information Management Association

65
Q

Contents encoded in three systems EMR, EHR, and PHR

A

Patient Record Content

66
Q

Information originates at the time of registration or admission
○ Name, address and telephone number
○ Insurance carrier
○ Policy number
○ Diagnoses and disposition at discharge

A

Patient Record Content: Identification Screen

67
Q

Used as clinical and administrative document

A

Patient Record Content: Identification Screen

68
Q

________ Identifies significant illness and operations and generally maintained over time by _______

A

Patient Record Content: Problem List; attending or primary care physician, or health care providers involved

69
Q

Lists medicines prescribed and administer and medication allergies

A

Medical Record (Medication Administration Record - MAR)

70
Q

Who are responsible for documenting and maintaining information in a Medical Record

A

Nursing Personnel

71
Q

History Component describes?

A

● Any major illnesses and surgeries the patient had
● Family history of disease
● Patient health habits
● Current medications
● Information is provided by the patient
● Documented by physician or other care provider

72
Q

What the physician found after the hands-on patient examination

A

Physical Component

73
Q

Physical and History Component need?

A

● Document the initial patient assessment
● Provide basis for diagnosis and treatment

74
Q

Made by physicians, nurses, therapists, social workers, and other staff members

A

Progress Notes

75
Q

Reflect patient’s response to treatment; observations and plans for continued treatment

A

Progress Notes

76
Q

What format should be followed on Progress Notes?

A

SOAP Format

Subjective findings
Objective findings
Assessment
Plan

77
Q

SOAP Format stands for?

A

Subjective findings
Objective findings
Assessment
Plan

78
Q

TRUE/FALSE: MTs are required to make progress notes.

A

False

79
Q

Records opinions about the patient’s condition

A

Consultation Note or Report

80
Q

Made by another health care provider at the request of the attending physician

May come from physicians and others inside or outside the organization

A

Consultation Note or Report

81
Q

Directions, instructions, or prescriptions

Given to other members of the health care team regarding the patient’s:
○ Medications
○ Tests
○ Diets
○ Treatments, and others

A

Physician’s Orders

82
Q

Responsibilities of the radiologist
○ Interpret images
○ Document interpretations or findings

A

Imaging & X-ray Reports

83
Q

TRUE/FALSE: Imaging & X-ray Reports should be documented in a timely manner.

A

TRUE

84
Q

Maintained in the radiology or imaging departments

A

Imaging & X-ray Reports

85
Q

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

A

Laboratory Reports

86
Q

Who documents lab results into the patient record

A

Laboratory Personnel

87
Q

Documents any findings and treatment plans based on lab results

A

Physicians

88
Q

TRUE/FALSE: Laboratory Results may or may not be available during treatment.

A

False (must be available)

89
Q

Consent as a legal document
○ Admission
○ Treatment
○ Surgery
○ Release of information

A

Consent & Authorization Forms

90
Q

Practitioner who provides treatment must obtain informed consent

A

Consent & Authorization Forms

91
Q

TRUE/FALSE: Consent & Authorization Forms should be signed by the patient.

A

True

92
Q

Describes any surgery performed

A

Operative Report

93
Q

Lists the names of surgeons and assistants

A

Operative Report

94
Q

Documents the information on the surgery performed

A

Surgeon

95
Q

Operative report includes:

A

○ Name of surgeons
○ Assisting surgeons
○ Anesthesiologist
○ Date of surgery
○ Preoperative diagnosis
○ Postoperative diagnosis
○ Indications for surgery

Prepared by the surgeons, however some assisting surgeons are given this task

96
Q

Describes tissue removed during any surgical procedure

A

Pathology Report

97
Q

Diagnosis based on examination

A

Pathology Report

98
Q

Documents the information for pathology reports

A

Pathologist

99
Q

Summarizes the hospital stay

A

Discharge Summary

100
Q

Summarizes the hospital stay including:

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

101
Q

Documents the discharge summary

A

Attending Physician

MT 637: HIS (3 decks)

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