Essentials of Health Information Management: Ch 5- Electronic Health Records

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30 days

Per the Joint Commission standards, inpatient hospital records must be completed within _____ after discharge regardless of the storage media of the record.

administration costs, admission times, medical errors

RHIO hospitals have reduced ___________, ________, and _________.

administrative

Patient scheduling application for EHR

administrative

Business/finance application for EHR

administrative

Admission/registration application for EHR

administrative savings, access records

With RHIOs, health plans/insurers experience ________ and can more efficiently ________.

altered

After a document is saved, it cannot be ______.

ambulatory care, physician offices, networking

During the 1990s, EMR systems were developed primarily for use in _________ and _________. There was limited _______ between facilities and departments.

american recovery and reinvestment act

This act included investment for health information technology to enhance the advancement of EHRs.

care, medical mistakes, costs

Electronic health records will improve _____ and reduce ______ and ______.

character

Smallest piece of data - letter, number.

clinical

Laboratory applications for EHR

clinical

Nursing applications for EHR

clinical

Pharmacy applications for EHR

clinical

Patient monitoring application for EHR

clinical

Medical documentation application for EHR

clinical

EHR application for the collection, storage, and display of laboratory, radiology, and nursing applications, etc.

clinical

Radiology applications for EHR

clinical data repository

The next step in the evolution of electronic records.

clinical data repository

Merging the data from different data systems into one centralized database in known as a _________.

clinical data repository

The merging of data from different data system into one centralized database. Provides easy access to data in electronic or printed form.

completion, time period, final saved, legal record

Facilities need to establish policies for document ________ and the _______ in which documents can be changed before they are ______ as part of the ______.

comprehensive documentation

In RHIOs, patients have access to __________.

computer based patient record

IOM felt that the best way to achieve a longitudinal record was through a ___________.

computer based patient record

CPR

computer based patient record

This has the ability to link patient information a different locations according to patient identifier and provides complete and accurate health problems, status and treatment data.

computerized medical records, alerts, medication administration records, provider orders, notes

Between 1970-1980, the term ________ was used to describe early medical record automation attempts. They focused on development of _____, _______, ______, _____.

computerized patient record

This term is was used interchangeably with electronic medical record in the 1990s.

coordination of care, patient safety

In RHIOs, patients have access to improved _________ and ______.

data

Raw facts not interpreted or processed.

demographic, insurance

One of the basic functions found in all EHR applications is the collection of patient _________ information and _________ information.

draft format

Facilities need to detail acceptable time frame with regard to how long a document can remain in _______.

electronic

Which type of record system provides more security?

electronic

Which type of record system allows more for customization?

electronic

Which type of record system provides for easier accessibilty?

electronic health record

This is the current term being used to describe the electronic medical record.

electronic health record

AHIMA defines the _______ as a computerized record of health information and associated processes.

electronic medical record

The term ________ was used starting in the late 1990s to describe systems that were based on imaging and the merging of data from various stand-along systems.

electronic records

________ require that facility hire technical staff to deal with tech issues.

electronic records

__________ are easily updated.

electronic records

_________ provide a timely capture of data.

electronic records

__________ improves readability.

electronic records

________ improves access to patient information

electronic records

________ allow multiple users to access patient information at the same time.

electronic records

_________ eliminate the need for paper record storage.

electronic records

__________ offer enhanced security.

electronic records

________ allow customized views and retrieval of information.

electronic records

_________ require more time to select and develop the system.

electronic records

________ require more time to train staff.

electronic records

People often are resistant to using ________.

electronic records

_________ require increased start up costs.

electronic records

_______ require more money to set up the system.

electronic records

________ allow for reduced administrative costs.

fastening devices, patient name, medical record number, repair, tears, copied, scanned

Before scanning documents ______ need to be removed. Then, the _________ needs to be verified and _______ should appear on each page. Third ________ any pages that have ______. Torn pages should be _____ and that should be _______.

field

Group of characters

file

Collection of related records

final saved, complete, accurate

Facilities need to develop the manner in which electronic documents are _____ and develop policies that facilitate a ________ and _____ record.

health data

Health facts that are collected about a patient or group of patients that describe a health issue.

health information

Health data that is analyzed and given meaning and is useful for decision making.

health information exchange

RHIOs allow access to health information from other facilities in the spirit of __________.

health level seven

The standards for the exchange of health information are being developed by _________.

health level seven

Organization that has developed standards which outline process for health information exchange and developing nationwide interoperability plan.

health level seven

Standards development organization that develops EHR standards under the direction of DHHS.

hybrid records

Mix of paper and electronic records

incentives, EHRs, HIE

ARRA offered ______ for adoption of ______ and promotes that advancement of _____

indexed

Scanned pages must be ________ which means that they are identified according to a unique identification number.

information

Data that has been collected and is given meaning for useful decision making.

laboratory

Applications that help to process laboratory orders and manage laboratory functions

late entry, amendment

Any corrections to a document after it is final saved must come in the form of a _______ or ______.

longitudinal patient record

A ____________ contains records from different episodes of care, providers, facilities that are linked to form a view, over time, of a patient's health care encounters.

longitudinal patient record

Vision of IOM in the early 1990s was to develop this type of record to document different episodes of a patient's health care encounters over time

medical documentation

Applications that assist with charting functions including progress notes, medication/diagnostic profiles, treatment planning, tracking of vital signs.

nursing

Applications that help to develop nursing intakes, document nursing care, medication administration records, charting functions.

paper

Which type of record system requires more time to set up?

paper

Which type of record system is least expensive?

paper

Which type of record system requires less training?

paper records

For __________, its hard to customize the retrieval of information.

paper records

_________ are automatically available with no downtime.

paper records

______ have low start up costs.

paper records

_____ require simple training.

paper records

______ require a less technically trained staff.

paper records

There is more difficulty abstracting information from ________.

paper records

__________ exhibit legibility issues.

patient care, test result delivery

RHIO hospitals have improved _________ and ________.

patient information

In RHIOs, physicians have rapid access to ________.

patient monitoring systems

A system that collects and monitors patient physiological data and records the information.

personal health record

An electronic or paper medical record maintained and updated by an individual for his or her own personal use is known as a ________.

pharmacy

Applications that automate order entry, identification of drug interactions, medical label printing, and drug usage reports.

privacy, HIPAA, non-HIPAA

ARRA promotes new ______ regulations for both ______ and ______ entities.

radiology

Applications that help with the ordering of test, creation of images (e.g., x-rays), reporting of results, and administrative function

record

collection of related fields

record transitional template

Used to detail the various sources of component parts of the patient record and distinguish between what is in electronic and paper format.

regional health information organizations

rhio

registration admission discharge transfer system

RADT

rhio

Electronic network of patient medical information gathered from multiple health care organizations within a region.

slow

According to the IOMs 1991 study, the health care industry's development of automated systems has been extremely _______.

workforce opportunities

ARRA promotes expansion of HIM ___________.

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