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Professional Development > PD IV Final Cards > Flashcards

PD IV Final Cards Flashcards

1
Q

Passive and Active Health IT

A

Passive - Information storage
Active - Reminders

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2
Q

Foundational interoperability

A

Allows data exchange with no interpretation or assignment to a patient

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3
Q

Structural interoperability

A

Data is exchanged with purpose and meaning of data intact

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4
Q

Semantic interoperability

A

Ability to exchange data, interpret it, and use the information that has been exchanged
Used in contiguous healthcare settings

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5
Q

Barriers to IT in healthcare

A

Cost
Complexity
Question of finincial return
Increased time to use IT
No streamlining between organizations

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6
Q

Components of an EHR

A

Demographics
Contact info
Communication
Encounters & Procedures
Testing
Advance directives

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7
Q

EHR templates

A

Template
Structured
OR
Unstructured

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8
Q

CPOE

A

Computerized Provider Order Entry
Allows for electronic ordering - can see what other people have ordered, no handwritten errors
Lets you know what is on the formulary

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9
Q

Clinical Decision Support System

A

Enhances ability to do what needs to be done
Reminders for routine testing
Tx suggestions for disease
Guidelines for abberant labs
Trend labs
Suggest diagnoses

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10
Q

PACS

A

Picture archiving/communication system
Helps with storage and access of imaging
Better access and use of images

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11
Q

Bar coding in medicine

A

Tracks what is given, etc.
Does not prevent wrong prescribing, etc.

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12
Q

RFID in medicine

A

Anti-elopement/Abduction
Inventory control
Equipment tracking
Tells where a patient is in the hospital

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13
Q

Automated medication dispensing machine

A

AMDS
Pyxis
Secures medication and ensures that medications are not duplicated
Can cause alarm fatigue

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14
Q

Electronic Materials Management

A

Make sure that supplies stay in stock
Prevent delays and false charges

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15
Q

Telemedicine structure

A

Distant/Hub sites with ongoing/spoke sites where the patient is
Asynchronous data collection
Remote patient monitoring devices

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16
Q

Teleradiologist

A

Interpret images remotely - must be done by a radiologist in the US

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17
Q

3 steps for provider reimbursement

A

Appropriate coding for diagnosis
Appropriate coding of services
Insurance determines appropriate fee

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18
Q

CPT

A

Current Procedural Coding
Quantifies complexities of an encounter

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19
Q

ICD-10

A

Billing codes for diagnosis
HIPAA required

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20
Q

Problem focused hx

A

CC,
Brief HPI w/ 1-3 elements,
no ROS or PFSH

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21
Q

Expanded Problem Focused Hx

A

CC,
Brief HPI 1-3 elements,
Problem pertinent ROS -one system,
No PFSH

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22
Q

Detailed Hx

A

CC, Extended
HPI 4+ elements or status of 3+ chronic conditions,
Extended ROS 2-9 systems,
Pertinent PFSH at least 1

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23
Q

Comprehensive Hx

A

CC,
Extended HPI 4+ elements or status of 3+ chronic conditions,
Complete ROS 10+ systems,
Complete PFSH two areas for established or 3 for new

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24
Q

How to implement non-provider info into an HPI

A

Make sure you go over it with the patient so that you can document it

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25
Q

Problem focused PE

A

1+ organ systems with 1-5 elements

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26
Q

Expanded problem focused PE

A

1+ organ systems with 6+ elements

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27
Q

Detailed PE

A

6+ organ systems with 2+ elements each
OR
2+ with 12+ elements in total

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28
Q

Comprehensive PE

A

9+ organ systems with 2+ elements each

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29
Q

Single system problem focused exam

A

1 to 5 elements in that system

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30
Q

Expanded problem focused single system exam

A

6+ elements in that system

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31
Q

Detailed single system exam

A

12+ elements
OR
9+ in eye/psych

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32
Q

Comprehensive single system exam

A

Look at all possible elements

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33
Q

Straightforward decision making level

A

Minimal Dx or Management options
Minimal/No Compleixty of data reviewed
Minimal risk of significant complications

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34
Q

Low complexity medical decision making

A

Limited number of dx or mgmt options
Limited data reviewed
Low risk of significant complications

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35
Q

Moderate complexity medical decision making

A

Multiple tx or mgmt options
Moderate amount/complexity of data reviewed
Moderate risk of significant complications

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36
Q

High complexity medical decision making

A

Extensive number of tx mgmt options
Extensive amount/complexity of data reviewed
High risk of significant complications

37
Q

Example of a straightforward MDM case

A

Self limiting minor problem
Order of non-invasive ordinary labs
Simple tx options

Sprained ankle

38
Q

Example of a low complexity MDM case

A

2+ minor problems, 1 stable chronic problem, or Acute uncomplicated illness
Moderately invasive tests and imaging
Various interventions such as minor surgery, OT or IV hydration

BPH

39
Q

Moderate MDM example

A

1+ chronic illness w/ exacerbation
2+ stable chronic illnesses
New problems with uncertainty
Complicated or systemic illness
Cardio imaging and more invasive testing
Major surgery w/ risk

40
Q

High MDM level

A

1+ chronic illness with acute axacerbation
Emergencies
Most invasive dx
Major or emergent surgeries

41
Q

2019 Changes to coding

A

Don’t need to document necessity of home visit
Less emphasis on H&P
Similar changes in 2021:
Merging higher complexities

42
Q

When was ICD-10 implemented

A

2015

43
Q

ICD-10 code format

A

3 for category: Alpha, Number, Alpha
3 for etiology, site, severity: 3 alpha OR numeric
Extension: #

Ex. A1A.123 4 OR A11.ABC 4

Not all codes are 7 characters - I10 is Essential HTN

44
Q

Symptom as a code

A

Oaky if you don’t have the dx yet - dx preferred

45
Q

NCCPA

A

Certifying body for PAs

46
Q

Initial certification for PAs

A

Graduate ARC-PA certified program
Pass the PANCE

47
Q

PA recertification

A

100hrs of CME every 2 years
$150 maintainence fee every 2 years
Pass recertification exam every 10 years

48
Q

PANCE exam taking requirements

A

$550 registration fee
Apply 90 days before expected completion date

49
Q

PANCE exam time and questions

A

Five 60 minute blocks w/ 45 minute break
300 questions total

50
Q

Time to take the pance

A

180 days to take after graduating

51
Q

How often can you take the PANCE

A

Once every 90 days
3 times per year
6 times total
6 year, 6 attempt rule

52
Q

Passing and highest possible PANCE score

A

800 = top score
350 = Passing

53
Q

Panre cost and structure

A

$350 - Apply 9th or tenth year of recert cycle
6 months to schedule
240 questions in four hours
Can choose practice focus

54
Q

PANRE-LA alternative

A

350 dollar registration fee
Completed in years 7-9
3 month blocks of 25 questions
Complete 8 quarters of blocks - can skip up to four
Open book

55
Q

Categories of CME

A

Category 1 - Formally planned activities - have to be documented
Category 2 - Does not require documentation - can be like talking to a doctor
Active learning!!
Need 50 hours of each in 2 years

56
Q

Minimum passing score for PANRE

A

Changes over time

57
Q

Four parameters that define scope of practice

A

Education and experience
State law
Facility policy
Needs of the practice

58
Q

Changes in scope of practice

A

Supervising/Collaborating physician needs to sign off on new skills, etc.

59
Q

Who is covered by HIPAA

A

Health plans
Health care providers
Health care clearinghouses
Business associates

60
Q

Protected information under HIPAA

A

Any information that is personally identifiable - including billing and payment info

61
Q

Non-protected information under HIPAA

A

De-identified health information

62
Q

When can information be released under HIPAA

A

As privacy rule permits or with written patient permission

63
Q

When must we release information

A

When individuals or their designated representative requests it
To Health and Human Services HIPAA investigators

64
Q

When can info be released without authorization

A

To the individual
For tx, payment and healthcare ops
When individual has opportunity to object
Incidental disclosures
Public interest
Limited data sets

65
Q

Psychotherapy notes and authorization

A

Often need specific clearance

66
Q

How much info to disclose

A

The minimum amount necessary -Not as heavily enforced

67
Q

What type of disclosure notice is provided

A

Notice of Privacy Practices

68
Q

Patient control over own health record

A

Amendment request if the feel it is incorrect
Statement of disagreement if ammendment denied
RIght to a statement of disclosures
Can request limitation of disclosure

69
Q

Requirements for individuals covered by HIPAA

A

Have privacy policy
Have training and enforcement
Mitigate harmful effects of mistakes
Data safeguards
No retaliation against patients exercising rights
No requirement to waive

70
Q

Civil HIPAA penalty

A

Non-malicious violation
100-50,000 dollars

71
Q

3 types of HIPAA criminal violations

A

Knowingly obtains or discloses
Obtains under false pretenses
Sell transfer or use information maliciously
Tier 1,2, or 3 respectively

72
Q

MCCs of nosocomial infections

A

Pneumonia
GI
UTI
Surgical wound

73
Q

Risk factors for nosocomial infections

A

Indwelling devices
Skin breaks
Contamination
Abx misuse
Improper sterilization

74
Q

Hospital never events - 8

A

Object left in patient after surgery
Hospital acquired UTI
Hospital acquired bloodstream infections
Administration of incompatible blood products
Air Embolism
Patient falls
Pressure ulcers
Certain surgical site infections

75
Q

Standard precautions

A

Baseline for all patients
Hand hygeine
Safe injection practice
PPE use as needed
Safe handling of fluids
Cough etiquette
Garbage and Laundry

76
Q

When must soap and water be used for hand hygeine

A

Visibly soiled hands or patients with infectious diarrhea -surgery

Otherwise alcohol based rub even if wearing gloves

77
Q

Use of gloves

A

Contact with blood or body fluids or potentially infectious materials

78
Q

Use of gowns

A

Contact precautions
May get body fluids on you
Surgery

79
Q

Facial PPE

A

Masks and Goggles
Procedures that cause splashes and sprays
Protect patients from anything you may have as well

80
Q

Injection safety

A

Clean vial septum
Don’t reenter a vial
Give patient own multidose vial if possible
Keep sharps nearby

81
Q

Critical items

A

ALWAYS have to be sterile - IV catheters or surgical tools

82
Q

Semi-critical items

A

Touch mucous membranes or non intact skin - Colonoscope

83
Q

Noncritical items

A

Touch intact skin only
BP Cuff

84
Q

Environmental surfaces

A

Generally do not contact patient
Routine cleaning and disinfection

85
Q

Reusable equipment

A

Clean and sterilize appropriately as needed

86
Q

Contact precautions

A

Spread by contact and fomites
Gown and gloves and patient dedicated equipment - may need special cleaning instructions

87
Q

Droplet precautions

A

Spread through respiratory contact
No gown but mask and goggles maybe
May consider gown or gloves

88
Q

Airborne precautions

A

Spread through air
Mask or respirator
Isolation with negative pressure ventilation - private room with door closed if not available

Professional Development (3 decks)

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