UNIT 6 (EHR)

Question 1

A Collection of computer-stored images of traditional health record documents.

Answer 1

Automated Health Records (AHR)

Question 2

It can Scanned into a computer and Stored on optical disks.

Answer 2

Automated Health Records (AHR)

Question 3

It Describes automated systems based on document imaging or systems

Answer 3

Electronic Medical Record (EMR)

Question 4

Developed within a medical practice or health center

Answer 4

Electronic Medical Record (EMR)

Question 5

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

Answer 5

Electronic Medical Record (EMR)

Question 6

It is the Collection of health information for one patient linked by a patient identifier

Answer 6

Computer-based Patient Record (CPR)

Question 7

-Medicalalerts
-Medicationorders
-Integrated data on a patient’s registration -Admission and financial details
-Recording information from nurses, laboratory, radiology, and pharmacy

Answer 7

Computer-based Patient Record (CPR)

Question 8

Contains all personal health information belonging to an individual

Answer 8

Electronic Health Record (EHR)

Question 9

It Entered and accessed electronically by healthcare providers over the person’s lifetime and Extends beyond acute inpatient situations

Answer 9

Electronic Health Record (EHR)

Question 10

True or 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.

Answer 10

True

Question 11

A Digital version of paper charts and Contains medical and treatment history of patients in one practice or organization

Answer 11

Electronic Medical Records (EMR)

Question 12

It Enables clinicians to
̶ Track data overtime
̶ Easily identify who are due for screenings or check ups
̶ Check their patients
̶Monitor and improve overall quality of care within the practice

Answer 12

Electronic Medical Records (EMR)

Question 13

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

Answer 13

Electronic Health Records (EHR)

Question 14

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 health care organization.

Answer 14

Electronic Medical Record

Question 15

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.

Answer 15

Electronic Health Record

Question 16

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.

Answer 16

Personal Health Record

Question 17

Major Issue:
What is a major issue that should be addressed before moving forward to automation.

Answer 17

Unique patient identification

Question 18

Major Issue:
What is the backbone of an effective and efficient health record system, whether manual or electronic?

Answer 18

Accurate Patient Identification

Question 19

True or False: Other possible issues are Clinical data entry issues and lack of standard terminology.

Answer 19

True

Question 20

True or False: Other possible issues are Resistance to computer technology and lack of computer literacy because Some prefer to write by hand and Some are still not proficient in using computers.

Answer 20

True

Question 21

True or False: Other Possible Issues are Strong resistance to change by many healthcare providers because it Requires intensive training of healthcare practitioners. It is also The change to entering patients’ health record data via a computer or other electronic device may be difficult.

Answer 21

True

Question 22

Other Possible Issues is High cost of computers and computer systems and funding limitations

Answer 22

It Needs to compare the current system costs plus perceived costs for the new EHR system

Question 23

Other Possible Issues is the Concern by providers as to whether information will be available on request

Answer 23

The Information should always be readily available and the Information can be accessed more efficiently

Question 24

Other Possible Issues are Concerns about privacy, confidentiality and the quality and accuracy of electronically generated information.

Answer 24

It is the Retention schedules and How information is to be retrieved

Question 25

Other Possible Issues are Quality of electronic healthcare information and accuracy of data entries

Answer 25

-Accuracy and validity of the original sourcedata -Reliability -Completeness -Legibility -Currency and timeliness -Accessibility

Question 26

Other Possible Issue is Lack of staff with adequate knowledge of disease classification systems

Answer 26

It is Limited coding training programs and Selected people who do not have a medical background

Question 27

Other Possible Issues is Manpower issues – lack of staff with adequate skills

Answer 27

-The Staff may be available, but their skills may not be adequate. -Well-trained workforce

Question 28

Other Possible Issues are Environmental issues

Answer 28

̶ Electrical wiring and supply of electricity ̶ Amount and quality of space needed for computers and other equipment

Question 29

Other Possible Issues are Involvement of clinicians and hospital administrators

Answer 29

̶ Thorough understanding of clinical data ̶ Their specifications and input ̶ Willingness to collaborate and share data

Question 30

Safeguards which may need to be addressed:

Answer 30

• Efficient back-up system available • Contingency plans for disaster recovery • Securing workstations and password requirement • Access control to authorized persons only • Audit controls

Question 31

Benefits of the Use of EHR Technology:

Answer 31

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

Question 32

This is to Secure website through which patients can electronically access their medical records

Answer 32

Patient Portal

Question 33

Enable users to: Complete forms online, Schedule appointments, Communicate with providers, Request refills on prescriptions, Review test results, Paybills

Answer 33

Patient Portal

Question 34

Factors that Increase EHR Adoption:

Answer 34

• Improve patient safety • Reduce medical errors • Reduce duplicate services • Improve organizational efficiency • Optimize reimbursement • Complete locally and regionally

Question 35

Barriers to Adoption: What is the Lack of capital or resources needed to develop, acquire, implement, and support a health care information system?

Answer 35

Financial

Question 36

Barriers to Adoption: It is Use and acceptance of changes in workflow.

Answer 36

Organizational or Behavioral

Question 37

It is Work and technology needed to build system interfaces.

Answer 37

Technical

Question 38

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

Answer 38

AHIMA (2016)

Question 39

It is Not managed by a health care organization or provider and Does not constitute a legal document of care But contains all pertinent healthcare information.

Answer 39

Personal Health Records (PHR)

Question 40

According to this organization, “...effective tool enabling patients to be active members of their own health care teams.”

Answer 40

AHIMA (2016)

Question 41

What is the Information originates at the time of registration or admission? ̶ Name,addressandtelephonenumber ̶ Insurancecarrier ̶ Policynumber ̶ Diagnosesanddispositionatdischarge

Answer 41

Identification Screen

Question 42

Used as clinical and administrative document

Answer 42

Identification Screen

Question 43

It Identifies significant illness and operations

Answer 43

Problem List

Question 44

It is Generally maintained over time. ̶ By attending or primary care physician, or Health care providers involved

Answer 44

Problem List

Question 45

A.K.A. Medication Administration Record (MAR)

Answer 45

Medical Record

Question 46

Lists medicines prescribed and administered and Lists medication allergies

Answer 46

Medical Record

Question 47

Nursing personnel are responsible for documenting and maintaining information

Answer 47

Medical Record

Question 48

History component describes:

Answer 48

-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

Question 49

What the physician found after the hands-on patient examination History or Physical?

Answer 49

Physical component states

Question 50

-Document the initial patient assessment -Provide basis for diagnosis and treatment History or Physical?

Answer 50

Both components

Question 51

Made by physicians, nurses, therapists, social workers, and other staff members and it Reflect patient’s response to treatment; observations and plans for continued treatment

Answer 51

Progress Notes

Question 52

SOAP format:

Answer 52

̶ Subjective findings ̶ Objective findings ̶ Assessment ̶ Plan

Question 53

It Records opinions about the patient’s condition

Answer 53

Consultation Note or Report

Question 54

It Made by another health care provider at the request of the attending physician and May come from physicians and others inside or outside the organization.

Answer 54

Consultation Note or Report

Question 55

Directions, instructions, or prescriptions

Answer 55

Physician’s Orders

Question 56

Given to other members of the health care team regarding the patient’s ̶ Medications ̶ Tests ̶ Diets ̶ Treatments,andothers

Answer 56

Physician’s Orders

Question 57

It is the Responsibilities of the radiologist which Interpret images and Document interpretations or findings.

Answer 57

Imaging and X-ray Reports

Question 58

Documented in a timely manner and Maintained in the radiology or imaging departments

Answer 58

Imaging and X-ray Reports

Question 59

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

Answer 59

Laboratory Reports

Question 60

It Documents lab results into the patient record.

Answer 60

Laboratory personnel

Question 61

Must be available during treatment

Answer 61

Laboratory Reports

Question 62

It will Document any findings and treatment plans based on lab results

Answer 62

Physicians

Question 63

True or False: Practitioner who provides treatment must obtain informed consent and signed by patients.

Answer 63

True

Question 64

Consent as a legal document ̶ Admission ̶ Treatment ̶ Surgery ̶ Releaseofinformation

Answer 64

Consent and Authorization Forms

Question 65

This Describes any surgery performed and Lists the names of surgeons and assistants.

Answer 65

Operative Report

Question 66

In Operative Report who will Document the information?

Answer 66

Surgeons

Question 67

Describes tissue removed during any surgical procedure and Diagnosis based on examination

Answer 67

Pathology Report

Question 68

In Pathology Report who will documents the information?

Answer 68

Pathologist

Question 69

Who will documents the discharge summary?

Answer 69

Attending physician