Test 2 Review

Question 0

what are 3 basic principles of documentation in an EHR?

Answer 0

• use specific language and avoid speculation
• specific observations or conversations
• objective facts, no opinions

Question 1

what are some of the items that are important in a chart for meaningful use?

Answer 1

CPOE, drug allergy checks, eprescribing, medication list, demographics, vital signs

Question 2

what are 4 things documentation should include?

Answer 2

date and time, reason for encounter, history and physical (H&P), and lab results

Question 3

chief complaint

Answer 3

reason for encounter

Question 4

progress notes

Answer 4

response to treatment, change in treatment, or diagnosis change

• mainly for physicians and consultants
• jobs such as social worker and dietician use this area for notes

Question 5

non-compliance

Answer 5

never use this term because someone may not do what they are told because of low health literacy

Question 6

basic parts of a chart

Answer 6

medical history, H&P, physician orders, progress and nursing notes, test results, flowcharts, and discharge summary

Question 7

when should a discharge plan begin?

Answer 7

when the patient is admitted

Question 8

how does a facility get reimbursed?

Answer 8

with documentation supporting intensity of evaluation and treatment based on levels 1-4: based on complexity of decision making and severity of disease

Question 9

upcoding

Answer 9

billing someone for a level higher than what their disease is considered

Question 10

what is informed consent?

Answer 10

the physician explains the risks and benefits and alternatives, the patient can either change their mind or agree, or the guardian can make the decision if the patient can’t

Question 11

how are EHR entries authenticated?

Answer 11

date and time, and first and last name with credentials

Question 12

how are corrections made or late entries added?

Answer 12

cross out the mistake with one line, note it as an error with name and credentials
-late entries must be noted as late and with the time of the actual observation, not the entry

Question 13

why are interdisciplinary teams important?

Answer 13

often one professional can’t meet all needs, as system is becoming more specialized and increased knowledge and skills needed

Question 14

multidisciplinary team

Answer 14

various disciplines caring for one patient but that is the only common goal, there is no “real” communication

Question 15

interdisciplinary team

Answer 15

IDT

have shared goal to optimize care and quality of life and they meet regularly to discuss patient

Question 16

inter-professional team

Answer 16

latest description of cross functional teams with knowledge of contribution
-basically newer word for interdisciplinary

Question 17

why did EHRs come into play?

Answer 17

to better organize and use health data and to make it easier to share patient data with other facilities

Question 18

interoperability

Answer 18

ability of different information technology systems and software applications to communicate, exchange data, and use information

Question 19

computerized physician order entry

Answer 19

CPOE

allows providers to prescribe, order tests, and give instructions electronically

Question 20

order-set

Answer 20

predefined list of orders that are most common to a particular diagnosis
-can be efficient but are sometimes ineffective because they don’t account for unique circumstances

Question 21

clinical decision support

Answer 21

CDS

• uses data to help providers make decisions regarding patient care
  ex) checking medications against patient data to ensure allergies or conflict

Question 22

meaningful use

Answer 22

the facility will actually collect data, not just “have it”

-“are you going to put the system to use?”

Question 23

HITECH Act of 2009

Answer 23

incentivized the use on EHR through rewards and penalties

Question 24

Health Information Exchange

Answer 24

HIE

sharing data between EHRs

Question 25

outcomes of using EHR

Answer 25

it is costly and can result in lost efficiency due to training, but improved 30 day mortality, inpatient mortality, and length of stay
-worsened readmission rates

Question 26

why no significant improvements with EHR?

Answer 26

not enough time to acclimate
tech not made to best fit the way they work
not enough places use it

Question 27

HIPAA

Answer 27

Healthcare Information Portability and Accountability Act

• 1st universal code to protect privacy
• gives the patient access to their record and ability to fix mistakes
• patient has right to know how info is shared and can’t give info to certain people

Question 28

comorbid

Answer 28

2 past diseases

Question 29

multimorbid

Answer 29

currently living with multiple diseases

Question 30

what is nomenclature

Answer 30

how you choose names for things and the process

ex) switching smartphone types doesn’t always work because the data is not mapped out the same

Question 31

medico

Answer 31

legal standard of care

Question 32

structured data

Answer 32

results in a file that are searchable and graphable

Question 33

unstructured data

Answer 33

data that is not in certain fields of the chart such as progress notes etc

Question 34

what is an audit function

Answer 34

authority can track who is looking in an EHR and when they were in it

Question 35

difference between EHR and EMR

Answer 35

EHR is the “big data,” the culmination of all visits

EMR is contained in one visit

Question 36

4 Benefits of EHR

Answer 36

track (tracking data), identify (seeing who’s due for screenings, etc), monitor (monitor patients at home care) and improve (improve quality of care)

Question 37

patient portal

Answer 37

online medical chart patient can access with a username and password

Question 38

what are the benefits of an EHR from a patient’s perspective?

Answer 38

less time filling out paperwork, less duplicate testing, reliable reminders, convenience, and online charts

Question 39

what is the item called that allows patient access to their own information?

Answer 39

patient portal

Question 40

SOAP method of charting

Answer 40

S-subjective data as described by patient
O-objective data derived from exam and test results
A-assessment by physician
P-plan for further investigation to diagnose, treat, and educate patient