Unit 6: Electronic Health Records (EHR) Flashcards by BEA BIANCA LAZO

Automated Health Records (AHR)

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T/F:
Automated Health Records (AHR) are scanned into a computer and stored on optical disks.

true

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Describe automated systems based on document imaging or systems

a. Electronic Health Records (EHR)
b. Electronic Medical Records (EMR)
c. Automated Health Records (AHR)
d. Computer-based Patient Record (CPR)

Electronic Medical Records (EMR)

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Developed within a medical practice or health center

a. Electronic Health Records (EHR)
b. Electronic Medical Records (EMR)
c. Automated Health Records (AHR)
d. Computer-based Patient Record (CPR)

Electronic Medical Records (EMR)

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EMR include the following except:

a. patient identification details
b. medications and prescription generation
c. financial details
d. laboratory results
e. healthcare information recorded by the doctor

financial details

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Collection of health information for one patient linked by a patient identifier

a. Electronic Health Records (EHR)
b. Electronic Medical Records (EMR)
c. Automated Health Records (AHR)
d. Computer-based Patient Record (CPR)

Computer-based Patient Record (CPR)

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CPR include the following except:

a. medication and treatment
b. medical alerts
̶c. medication orders
d. integrated data on a patient’s registration
e. admission and financial details
f. recording information from other departments

medication and treatment

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Contains all personal health information belonging to an individual

a. Electronic Health Records (EHR)
b. Electronic Medical Records (EMR)
c. Automated Health Records (AHR)
d. Computer-based Patient Record (CPR)

Electronic Health Records (EHR)

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Entered and accessed electronically by healthcare providers over the person’s lifetime

a. Electronic Health Records (EHR)
b. Electronic Medical Records (EMR)
c. Automated Health Records (AHR)
d. Computer-based Patient Record (CPR)

Electronic Health Records (EHR)

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T/F:
EHR extends beyond acute inpatient situations

true

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T/F:
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.

true

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Digital version of paper charts

a. EMR
b. EHR

EMR

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Contains medical and treatment history of patients in one practice or organization

a. EMR
b. EHR

EMR

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EMR enable clinicians to do the following except:

a. track data over time
̶b. easily identify who are due for screenings or checkups
̶c. access all information of the patient
̶d. check their patients
e. monitor and improve overall quality of care within the practice

access all information of the patient

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Focus on the total health of the patient

a. EMR
b. EHR

EHR

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Going beyond standard clinical data collected

a. EMR
b. EHR

EHR

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Share information with other health care providers and organizations

a. EMR
b. EHR

EHR

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Decision-support capabilities

a. EMR
b. EHR

EHR

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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

a. Electronic Medical Record (EMR)
b. Electronic Health Record (EHR)
c. Personal Health Record (PHR)

Electronic Medical Record (EMR)

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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

a. Electronic Medical Record (EMR)
b. Electronic Health Record (EHR)
c. Personal Health Record (PHR)

Electronic Health Record (EHR)

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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

a. Electronic Medical Record (EMR)
b. Electronic Health Record (EHR)
c. Personal Health Record (PHR)

Personal Health Record (PHR)

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T/F:
Unique patient identification is a major issue that should be addressed before moving forward to automation.

true

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The backbone of an effective and efficient health record system, whether manual or electronic

a. reliability of electronic data
b. accurate patient identification
c. treatment and medication efficacy
d. literacy in computer technology

accurate patient identification

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Another possible issue that should be resolved through adopting a standard, comprehensive vocabulary and developing a data dictionary a. resistance to computer technology and lack of computer literacy b. quality of electronic healthcare information and accuracy of data entries c. lack of staff with adequate knowledge of disease classification systems d. clinical data entry issues and lack of standard terminology

clinical data entry issues and lack of standard terminology

Another possible issue where some prefer to write by hand, and some are still not proficient in using computers a. strong resistance to change by many healthcare providers b. lack of staff with adequate knowledge of disease classification systems c. resistance to computer technology and lack of computer literacy d. clinical data entry issues and lack of standard terminology

resistance to computer technology and lack of computer literacy

Another possible issue where the change to entering patients’ health record data via a computer or other electronic device may be difficult a. lack of staff with adequate knowledge of disease classification systems b. strong resistance to change by many healthcare providers c. resistance to computer technology and lack of computer literacy d. clinical data entry issues and lack of standard terminology

strong resistance to change by many healthcare providers

Another possible issue where there is a need to compare the current system costs plus perceived costs for the new EHR system a. quality of electronic healthcare information and accuracy of data entries b. manpower issues: lack of staff with adequate skills c. high cost of computers and computer systems and funding limitations d. concerns about privacy, confidentiality, quality, and accuracy

high cost of computers and computer systems and funding limitations

Another possible issue where information should always be readily available and can be accessed more efficiently a. quality of electronic healthcare information and accuracy of data entries b. manpower issues: lack of staff with adequate skills c. concern by providers as to whether information will be available on request d. concerns about privacy, confidentiality, quality, and accuracy

concern by providers as to whether information will be available on request

Another possible issue related to retention schedules and how information is to be retrieved a. quality of electronic healthcare information and accuracy of data entries b. clinical data entry issues and lack of standard terminology c. concern by providers as to whether information will be available on request d. concerns about privacy, confidentiality, quality, and accuracy

concerns about privacy, confidentiality, quality, and accuracy

Another possible issue related to accuracy and validity of the original source data, reliability, completeness, legibility, currency and timeliness, and accessibility a. quality of electronic healthcare information and accuracy of data entries b. clinical data entry issues and lack of standard terminology c. concern by providers as to whether information will be available on request d. concerns about privacy, confidentiality

quality of electronic healthcare information and accuracy of data entries, quality, and accuracy

Another possible issue associated with limited coding training programs where selected people do not have a medical background a. manpower issues: lack of staff with adequate skills b. lack of staff with adequate knowledge of disease classification systems c. concern by providers as to whether information will be available on request d. strong resistance to change by many healthcare providers

lack of staff with adequate knowledge of disease classification systems

Another possible issue where the staff may be available, but their skills may not be adequate a. manpower issues: lack of staff with adequate skills b. lack of staff with adequate knowledge of disease classification systems c. concern by providers as to whether information will be available on request d. strong resistance to change by many healthcare providers

manpower issues: lack of staff with adequate skills

Another possible issue associated with electrical wiring and supply of electricity and amount and quality of space needed for computers and other equipment a. resistance to computer technology and lack of computer literacy b. environmental issues c. strong resistance to change by many healthcare providers d. high cost of computers and computer systems and funding limitations

environmental issues

The following are safeguards which many need to be addressed except: a. data redundancy and replication b. efficient back-up system available c. contingency plans for disaster recovery d. securing workstations and password requirement e. access control to authorized persons only f. audit controls

data redundancy and replication

The following are benefits of the use of EHR technology except: a. Improve health care quality, safety, and efficiency and reduce health disparities b. Engage patients and families in their health care c. Elevate patient safety and security

Elevate patient safety and security

The following are benefits of the use of EHR technology except: a. Strengthen technological collaboration and cooperation b. Improve care coordination c. Improve population and public health d. Ensure adequate privacy and security of personal health information

Strengthen technological collaboration and cooperation

Secure website through which patients can electronically access their medical records a. mHealth b. patient portal c. telehealth platforms d. remote patient monitoring

patient portal

Enable users to complete forms online, schedule appointments, communicate with providers, request refills on prescriptions, review test results, and pay bills a. mHealth b. patient portal c. telehealth platforms d. remote patient monitoring

patient portal

The following are considered factors that increase EHR adoption except: a. Improve patient safety b. Reduce medical errors c. Increase duplicate services d. Improve organizational efficiency e. Optimize reimbursement f. Complete locally and regionally

Increase duplicate services (should be reduced)

Which barrier to adoption is associated with the lack of capital or resources needed to develop, acquire, implement, and support a health care information system? a. technical b. financial c. organizational or behavioral

financial

Which barrier to adoption is associated with the use and acceptance of changes in workflow? a. technical b. financial c. organizational or behavioral

organizational or behavioral

Which barrier to adoption is associated with the work and technology needed to build system interfaces a. technical b. financial c. organizational or behavioral

technical

According to AHIMA (2016) it is a "…tool to collect, track, and share past and current information about your health or the health of someone in your care.” a. EHR b. EMR c. AHR d. PHR

PHR

T/F: PHR is managed by a healthcare organization or provider

false

T/F: PHR constitutes a legal document of care

false (does not constitute but contains all pertinent healthcare information)

According to AHIMA (2016) it is an “…effective tool enabling patients to be active members of their own health care teams.” a. EHR b. EMR c. AHR d. PHR

PHR

Information originates at the time of registration or admission including the name, address, and telephone number a. authentication system b. access control c. identification screen d. audit trail

identification screen

used as a clinical and administrative document a. authentication system b. access control c. identification screen d. audit trail

identification screen

Identifies significant illness and operations a. problem list b. diagnostic test results c. problem-oriented documentation d. immunization records

problem list

T/F: Problem lists are generally maintained over time by an attending or a primary care physician or healthcare providers involved.

true

Medical record is also known as: a. Medical Administration Record (MAR) b. Medication Compliance Record (MCR) c. Medication Dispensing System (MDS) d. Medication Administration Record (MAR)

Medication Administration Record (MAR)

Lists medicines prescribed and administered and medication allergies a. electronic medical record b. medical record c. automated health records d. computer-based patient record

medical record

Responsible for documenting and maintaining information on the medical record a. pharmacist b. attending physician c. nursing personnel d. radiologist

nursing personnel

describes any major illnesses and surgeries the patient had, family history, patient health habits, and current medications a. history component b. physical component c. both d. none

history component

information is provided by the patient and documented by physician or other care providers a. history component b. physical component c. both d. none

history component

states what the physician found after the hands-on patient examination a. history component b. physical component c. both d. none

physical component

document the initial patient assessment a. history component b. physical component c. both d. none

both

provide basis for diagnosis and treatment a. history component b. physical component c. both d. none

both

Reflect patient’s response to treatment and observations and plans for continued treatment made by healthcare providers a. care plans b. clinical summaries c. progress notes d. discharge summaries

progress notes

most common format of progress notes a. DAP (Data, Assessment, Plan) b. SOAP (Subjective findings, Objective findings, Assessment, Plan) c. BIRP (Behavior, Intervention, Response, Plan) d. CHART (Chief complaint, History, Assessment, Rx, Test/Study)

SOAP (Subjective findings, Objective findings, Assessment, Plan)

Records opinions about the patient’s condition made by another health care provider at the request of the attending physician a. consultation note or report b. referral notes c. progress notes d. case conference reports

consultation note or report

Directions, instructions, or prescriptions given to other members of the health care team regarding the patient’s medications, tests, diets, and treatments a. advance directives b. physician's orders c. diagnostic orders d. nursing orders

physician's orders

Responsibilities of a ________ includes interpreting images and documenting interpretations or findings. a. physician b. nurse c. radiologist d. pharmacist

radiologist

Contain results of tests conducted on body fluids, cells, and tissues that must be available during treatment a. pathology reports b. microbiology reports c. urinalysis reports d. laboratory reports

laboratory reports

document lab results into the patient record a. nursing personnel b. medical technologist c. physician d. laboratory personnel

laboratory personnel

document any findings and treatment plans based on lab results a. nursing personnel b. medical technologist c. physicians d. laboratory personnel

physicians

Which of the following require consent as a legal document? a. admission b. treatment c. surgery d. release of information e. all of the above

all

T/F: Practitioner who provides treatment must obtain informed consent, and the consent and authorization forms must be signed by patients

true

Describes any surgery performed and lists the names of surgeons and assistants a. discharge summary b. operative reports c. pathology reports d. laboratory reports

operative reports

documents the information of operative reports a. nurse b. physician c. surgeon d. pathologist

surgeon

Describes tissue removed during any surgical procedure, in which diagnosis is based on examination a. discharge summary b. operative reports c. pathology reports d. laboratory reports

pathology reports

documents the information of pathology reports a. nurse b. physician c. surgeon d. pathologist

pathologist

Summarizes the hospital stay including reason for admission, significant findings from tests, procedures performed, etc. a. discharge summary b. operative reports c. pathology reports d. laboratory reports

discharge summary

documents the discharge summary a. nurse b. physician c. surgeon d. pathologist

physician