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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
Problem focused PE
1+ organ systems with 1-5 elements
26
Expanded problem focused PE
1+ organ systems with 6+ elements
27
Detailed PE
6+ organ systems with 2+ elements each OR 2+ with 12+ elements in total
28
Comprehensive PE
9+ organ systems with 2+ elements each
29
Single system problem focused exam
1 to 5 elements in that system
30
Expanded problem focused single system exam
6+ elements in that system
31
Detailed single system exam
12+ elements OR 9+ in eye/psych
32
Comprehensive single system exam
Look at all possible elements
33
Straightforward decision making level
Minimal Dx or Management options Minimal/No Compleixty of data reviewed Minimal risk of significant complications
34
Low complexity medical decision making
Limited number of dx or mgmt options Limited data reviewed Low risk of significant complications
35
Moderate complexity medical decision making
Multiple tx or mgmt options Moderate amount/complexity of data reviewed Moderate risk of significant complications
36
High complexity medical decision making
Extensive number of tx mgmt options Extensive amount/complexity of data reviewed High risk of significant complications
37
Example of a straightforward MDM case
Self limiting minor problem Order of non-invasive ordinary labs Simple tx options Sprained ankle
38
Example of a low complexity MDM case
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
Moderate MDM example
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
High MDM level
1+ chronic illness with acute axacerbation Emergencies Most invasive dx Major or emergent surgeries
41
2019 Changes to coding
Don't need to document necessity of home visit Less emphasis on H&P Similar changes in 2021: Merging higher complexities
42
When was ICD-10 implemented
2015
43
ICD-10 code format
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
Symptom as a code
Oaky if you don't have the dx yet - dx preferred
45
NCCPA
Certifying body for PAs
46
Initial certification for PAs
Graduate ARC-PA certified program Pass the PANCE
47
PA recertification
100hrs of CME every 2 years $150 maintainence fee every 2 years Pass recertification exam every 10 years
48
PANCE exam taking requirements
$550 registration fee Apply 90 days before expected completion date
49
PANCE exam time and questions
Five 60 minute blocks w/ 45 minute break 300 questions total
50
Time to take the pance
180 days to take after graduating
51
How often can you take the PANCE
Once every 90 days 3 times per year 6 times total 6 year, 6 attempt rule
52
Passing and highest possible PANCE score
800 = top score 350 = Passing
53
Panre cost and structure
$350 - Apply 9th or tenth year of recert cycle 6 months to schedule 240 questions in four hours Can choose practice focus
54
PANRE-LA alternative
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
Categories of CME
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
Minimum passing score for PANRE
Changes over time
57
Four parameters that define scope of practice
Education and experience State law Facility policy Needs of the practice
58
Changes in scope of practice
Supervising/Collaborating physician needs to sign off on new skills, etc.
59
Who is covered by HIPAA
Health plans Health care providers Health care clearinghouses Business associates
60
Protected information under HIPAA
Any information that is personally identifiable - including billing and payment info
61
Non-protected information under HIPAA
De-identified health information
62
When can information be released under HIPAA
As privacy rule permits or with written patient permission
63
When must we release information
When individuals or their designated representative requests it To Health and Human Services HIPAA investigators
64
When can info be released without authorization
To the individual For tx, payment and healthcare ops When individual has opportunity to object Incidental disclosures Public interest Limited data sets
65
Psychotherapy notes and authorization
Often need specific clearance
66
How much info to disclose
The minimum amount necessary -Not as heavily enforced
67
What type of disclosure notice is provided
Notice of Privacy Practices
68
Patient control over own health record
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
Requirements for individuals covered by HIPAA
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
Civil HIPAA penalty
Non-malicious violation 100-50,000 dollars
71
3 types of HIPAA criminal violations
Knowingly obtains or discloses Obtains under false pretenses Sell transfer or use information maliciously Tier 1,2, or 3 respectively
72
MCCs of nosocomial infections
Pneumonia GI UTI Surgical wound
73
Risk factors for nosocomial infections
Indwelling devices Skin breaks Contamination Abx misuse Improper sterilization
74
Hospital never events - 8
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
Standard precautions
Baseline for all patients Hand hygeine Safe injection practice PPE use as needed Safe handling of fluids Cough etiquette Garbage and Laundry
76
When must soap and water be used for hand hygeine
Visibly soiled hands or patients with infectious diarrhea -surgery Otherwise alcohol based rub even if wearing gloves
77
Use of gloves
Contact with blood or body fluids or potentially infectious materials
78
Use of gowns
Contact precautions May get body fluids on you Surgery
79
Facial PPE
Masks and Goggles Procedures that cause splashes and sprays Protect patients from anything you may have as well
80
Injection safety
Clean vial septum Don't reenter a vial Give patient own multidose vial if possible Keep sharps nearby
81
Critical items
ALWAYS have to be sterile - IV catheters or surgical tools
82
Semi-critical items
Touch mucous membranes or non intact skin - Colonoscope
83
Noncritical items
Touch intact skin only BP Cuff
84
Environmental surfaces
Generally do not contact patient Routine cleaning and disinfection
85
Reusable equipment
Clean and sterilize appropriately as needed
86
Contact precautions
Spread by contact and fomites Gown and gloves and patient dedicated equipment - may need special cleaning instructions
87
Droplet precautions
Spread through respiratory contact No gown but mask and goggles maybe May consider gown or gloves
88
Airborne precautions
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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