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RES > RES: MODULE 3 PART 2 > Flashcards

RES: MODULE 3 PART 2 Flashcards

1
Q

The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts

A

CLINICAL DECISION SUPPORT (CDS)

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2
Q

A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions

A

CLINICAL DECISION SUPPORT SYSTEMS (CDSS)

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3
Q

Electronic results can be displayed automatically for care providers to improve effectiveness and efficiency of treatment while reducing cost of care by eliminating duplicate testing

A

RESULTS MANAGEMENT

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4
Q

Provides physicians and other providers the ability to place orders via the computer from any number of locations and adds decision support capability to enhance patient safety

A

Computerized Provider Order-Entry (CPOE) / Computerized Physician Order-Entry / Computerized Provider Order Management (CPOM)

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5
Q

This provides for effective and efficient patient care through decision making tools that are not currently available in paper-based health record systems

A

CLINICAL DECISION SUPPORT SYSTEMS (CDSS)

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6
Q

Health record should not be just a simple repository of patient care data

A

CLINICAL DECISION SUPPORT SYSTEMS (CDSS)

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7
Q

Assist healthcare providers in the actual diagnosis and treatment of patients

A

CLINICAL DECISION SUPPORT SYSTEMS (CDSS)

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8
Q

Review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends before problems become evident

A

CLINICAL DECISION SUPPORT TOOLS

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9
Q

Can recall relevant diagnostic criteria and treatment options on the basis of the data in the records

A

CLINICAL DECISION SUPPORT TOOLS

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10
Q

Supports the physician as he or she considers various diagnostic and treatment alternatives

A

CLINICAL DECISION SUPPORT TOOLS

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11
Q

WHATARE THE INSTITUTE OF MEDICINE KEY CAPABILITIES OF EHR SYSTEMS (EVOLUTION OF EHRS IN HOSPITALS)

A
  • Health information and data
  • Results management
  • Order entry management
  • Decision support
  • Electronic communication and connectivity
  • Patient support
  • Administrative process
  • Reporting and population health management
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12
Q

Providers have voiced out the lack of interoperability because it greatly limits the progression of specialties such as pain management

A

LACK OF INTEROPERABILITY

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13
Q

Stymies efforts of information governance and information sharing between organizations

A

LACK OF INTEROPERABILITY

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14
Q

It must be improved to create standardization for data that can or will be staged for a data warehouse

A

LACK OF INTEROPERABILITY

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15
Q

WHAT ARE THE USES OF EHR

A
  1. Reduce medical errors
  2. Provide more effective methods of communicating and sharing information among clinicians
  3. Lower national health care costs, better
    management patient medical records
  4. Improve coordination of care and health care
    quality condition, response to care, treatment course, and any deviation from standard treatment/reason)
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16
Q

WHATARE THE 2 TYPES OF DATA IN HEALTH RECORD

A
  1. CLINICAL DATA
  2. ADMINISTRATIVE DATA
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17
Q

Documents the patient’s medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided

A

CLINICAL DATA

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18
Q

Include demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information

A

ADMINISTRATIVE DATA

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19
Q

WHATARE THE 4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION?

A
  1. Facility- specific standards
  2. Licensure requirements
  3. certificate standards
  4. accreditation standrds
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20
Q

4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION:

  1. Standards might be found in facility policies and procedures and, when a facility has an organized medical staff in the medical staff bylaws, rules, and regulations
  2. Facility-specific guidelines govern the practice of physicians and others within a specific organization
A

FACILITY-SPECIFIC STANDARDS

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21
Q

4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION:

Before they can provide services, most healthcare organizations must be licensed by government entities such as the state or country in which they are located and must maintain a licenses as long as care is provided

A

LICENSURE REQUIREMENTS

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22
Q

4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION:

1.Government reimbursement program standards are applied to facilities that choose to participate in federal programs such as Medicare and Medicaid
2. These standards are titled conditions of participation or conditions for coverage. Facilities are said to be certified if the standards are met

A

CERTIFICATION STANDARDS

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23
Q

4 MAIN SOURCES OF STANDARDS FOR DOCUMENTATION:

Accreditation is the end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization

A

ACCREDITATION STANDARDS

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24
Q

The following are description of alternatives aside from the four main sources for standard of documentation guidelines:

A
  1. State regulating agencies
  2. Medicare and Medicaid programs
  3. Accreditation organizations
  4. The joint commission
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25
Q
  1. Document current observations, outcomes and progress
  2. Entries should be consistent with documentation in the record (e.g. flow charts)
  3. If the documentation is contradictory, an explanation should be included
A

CONSISTENCY

26
Q

State the facts about patient care and treatment and avoid documenting opinions:

A

OBJECTIVE DOCUMENTATION

27
Q

If other patient(s) are referenced in the record, do not document their name(s) instead reference their patient number(s) instead

A

REFERENCING OTHER PATIENTS

28
Q

Documentation entries in the patient record are considered permanent and policies and procedures should be established to prevent falsification of and tampering with the record

A

PERMANENCY

29
Q
  1. Select white paper with permanent black printing to ensure readability of paper-based record, not photocopies
  2. File original documents in the patient record, not photocopies
  3. Avoid using labels on reports because they can become separated from the report
A

PHYSICAL CHARACTERISTICS

30
Q
  1. Be sure to document specific information about patient care and treatment. Avoid vague entries
  2. Incorrect: Eye exam is normal
  3. Correct: Eye exam reveals pupils equal, round
    and reactive to light
A

SPECIFICITY

31
Q

PATIENT RECORD DOCUMENTATION GUIDELINES: Entries should be documented and signed (authenticated by the author)

A

AUTHENTICATION

32
Q

PATIENT RECORD DOCUMENTATION GUIDELINES: If the patient’s condition changes or significant patient care issue develops, documentation must reflect this as well as indicate follow-through

A

CHANGE IN PATIENT’S CONDITION

33
Q
  1. Significant information related to patient’s care and treatment should be documented (e.g. patient
  2. Evidence of the patient’s family participation in decision making
  3. Evaluation reports from each service
  4. Reports of staff conferences
  5. Progress reports
  6. Correspondence related to the patient
  7. Release forms
  8. Discharge summary
  9. Follow-up reports
A

COMPLETENESS

34
Q

Focus of services in physical medicine and rehabilitation is increasing a patient’s ability to function independently within the parameters of the individual’s illness or disability

A

REHABILITATION SERVICE DOCUMENTATION

35
Q

Documentation requirements for rehabilitation facilities vary because facilities range from comprehensive inpatient care to outpatient services or special program

A

REHABILITATION SERVICE DOCUMENTATION

36
Q

What are the document standards?

A
  1. Patient identification data
  2. Pertinent history, including functional history
  3. Diagnosis of disability / functional diagnosis
  4. Rehabilitation problems, goals, and
    prognosis
  5. Reports of assessments and program plans
  6. Reports from referring sources and service
    referrals
  7. Reports from outside consultation and
    laboratory, radiology, orthotic and prosthetic
    services
  8. Designation of a manager for patient’s
    program
37
Q

A computer software with a licensing provision that enables the users to modify, utilize, and distribute unmodified or modified version

A

OPEN-SOURCE SOFTWARE (OSS)

38
Q

Has freely available source code

A

OPEN-SOURCE SOFTWARE (OSS)

39
Q

Anyone can modify and distribute the code without the licensing fees, as defined in the software’s license unlike proprietary software

A

OPEN-SOURCE SOFTWARE (OSS)

40
Q

No system is free. All systems will have implementation and maintenance costs

A

OPEN-SOURCE SOFTWARE (OSS)

41
Q

what are the 5 systems of open source EHR

A
  1. OpenMRS
  2. BAHMNI
  3. GNU HEALTH
  4. OPEN VISTA AND WORLDVISTA
42
Q

Is a community-driver EHR platform supporting over 8.7 million active patients in 3,307 sites across over 64 countries

A

OpenMRS

43
Q

There are atleast five national implementation with hundreds of sites each, including Kenya, Mozambique, the Philippines and Uganda. OpenMRS follows international standards, such as FHIR, is modular so functionality can be added through modules, and has customizable forms and a data dictionary

A

OpenMRS

44
Q

Meant for a clinical implementation and has practice management functionality

A

OpenMRS

45
Q

Consists of OpenMRS for clinical functionality, OpenELIS for laboratory management, dcm4chee for imaging and OpenERP or odoo for practice management and logistics

A

BAHMNI

46
Q

It is implemented in over 8 countries and
has a list of vendors or implementation
partners that can be hired to provide

A

BAHMNI

47
Q

Is an EHR and laboratory management system that has been adopted by the United Nations University and is an official project of GNU

A

GNU HEALTH

48
Q

Has functionality for many areas of a hospital, GNU Health’s forms and data dictionary cannot be modified

A

GNU HEALTH

49
Q

Developed by the US Department of Veterans Affairs

A

OpenVistA and WorldVistA

50
Q

Used in more than 140 hospitals

A

OpenVistA and WorldVistA

51
Q

Have all necessary fratures for a complex hospital system, including functionality for EHRS, financials, laboratories, radiologym pharmacies, and other population health

A

OpenVistA and WorldVistA

52
Q

Used mostly in the United States, they have also been implemented in Egypt, Finland, Germany, and Mexico

A

OpenVistA and WorldVistA

53
Q

Is one of the only open source EHRs certified by the Office of the National Coordinator (ONC) of the US Department of Health and Human Services

A

OpenEMR

54
Q

Downloaded more than 7,000 times per month and has functionality for a patient portal, patient scheduling, EHRs, billing, and reports

A

OpenEMR

55
Q

Has certified vendors in 13 countries including Argentina, the United Kingdom, and the United States

A

OpenEMR

56
Q

An application which enables design of customized medical records system with no programming knowledge (although medical and systems analysis knowledge is required)

A

OpenMRS

57
Q

A community of people working to apply health information technologies to solve problems, primarily in resource-poor environments

A

OpenMRS

58
Q

Most popular open source electronic health records and medical practice management solution

A

Open EMR

59
Q

superior alternative to its proprietary counterparts. With passionate volunteers and contributors dedicated to guarding OpenEMR’s status as a free, open source software solution for medical practices with a commitment to openness, kindness and cooperation

A

Open EMR

60
Q

Main feature includes appointment scheduling e- prescribing, compliance, tracking, charting, voice recognition, billing and patient portal

A

Open EMR

RES (11 decks)

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