Certified EHR specialist exam

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EHR certification exam

Most medical errors occur...

Lost medical records, miscommunicated pt requests, unreadable information & mislabeled lab specimens

Year HIPAA act started

1996

President who recommended HIT in 2004

George Bush

the goal for all Americans to be using EHR was to take place in how many years?

10 years

ONCHIT

Office of National Coordination for Health Information Technology

Why ONCHIT was established

To have all Americans using EHR by 2014

HITSP

identified standards for the electronic exchange of health information

CCHIT

developed certification criteria for EHR software

The institute of medicine suggests 8 core functions:

Health information, results management, order management, decision support, electronic communications, patient support, administrative processes & reporting & population management

EMR

Electronic Medical Records

What are Electronic Medical Records?

Computerized records of one physician's encounter with a patient over time.

EHR

Electronic Health Records

What are Electronic Health Records?

Reflects data from all sources that have treated the individual.

PHR

Personal Health Records

Who Personal Health Records belong to?

Maintained and owned by the patient.

Acute care

hospital

Ambulatory care

without admission to a hospital

Advantages of EHR

safety, quality of care, efficiency & cost reduction

total conversion

allows patient data to be converted at once while still servicing patients

incremental conversion

gradual change to electronic records.

advantage of incremental conversion

lower costs & smoother transition

hybrid conversion

combination of paper & electronic forms of data

clinical vocabularies

set of common definitions for medical terms

SNOMED-CT is for:

clinical vocabulary designed to encompass all terms used in medicine and lab result contents

LOINC

terms & codes used for electronic exchange of lab results & clinical observations

UMLS

thesaurus database of medical terms

ICD-9 diagnosis usage

13,000, 3-5 alphanumeric codes for inpatient & outpatient care

ICD-9 procedure usage

4,000, 3-4 numeric codes for inpatient care

ICD-10-CM diagnosis usage

120,000, 3-7 alphanumeric codes for inpatient & outpatient care

ICD-10-PCS procedure usage

200,000, 7 alphanumeric codes for inpatient care

CPT

Current Procedural Terminology

What is Current Procedural Terminology?

coding procedural terminology developed and maintained by the AMA

Evaluation & management code range

99201-99499

HCPCS

Healthcare Common procedure Coding System

What is the Healthcare Common procedure Coding System?

contains codes for products, supplies & certain services not included in the CPT manual

Who maintains HCPCS?

Center for Medicare & Medicaid Services (CMS)

Messaging standards

make it possible to transfer data from systems such as laboratory or pharmacy systems

examples of messaging standards include:

HL7, DICOM, NCPDP & IEEE1073

LOINC

Logical Observation Identifiers Names & Codes

HL7

Health Level Seven

What Health Level Seven version 2.3+ is for:

scheduling, medical record & image management, patient administration, observation reporting, financial management, public health notification & patient care

(NCPDP) SCRIPT

National Council for Prescription Drug Programs

What National Council for Prescrioption Drug Program is for:

Retail pharmacy transactions

Who is in charge of device-device connectivity?

Institute of Electrical and Electronics Engineers, Inc.

DICOM

Digital Imaging & Communications in Medicine

What DICOM does

image information to workstations

HL7 Version 2.4 is for

demographics

SNOMED-CT

Systematized Nomenclature of Medicine clinical terms

HL7 Version 2.x+ is for:

units of measure

HL7 Version 2,3,1

specifically the Vaccines Administered & Manufacturers of Vaccines external code sets maintained by CDC,& NIP

CDC

Center for Disease Control & Prevention

NIP

National Immunization Program

LOINC is for

lab test order names

SNOMED CT is for

Nonlaboratory names

HIPAA Transactions & Code Sets

concerned with financial payment

Human Genome Nomenclature

concerned with genes

Environmental Protection Agency Substance Registry System

concerned with chemicals

Components of verbal communication

sound, words, speaking & language

Components of nonverbal communication

eye contact, body language, facial expression or symbolic expression

Patient flow

1. scheduling & information gathering, 2. check in, payment collection, 3. rooming, 4. checkout, 5. coding & billing & reviewing test results

chief complaint

verbal account made by the patient describing their problem

EHR clinical toolsq

order tests, order medications, & send prescriptions, screen for illness, identify at risk patients & aid with disease management

EHR billing & coding

facilitates claim processing

E-prescribing advantages

ability to quickly perform safety checks

primary benefits of hospital EHR

unlimited access to pt records, decreased waiting time for medication delivery & test results and increased efficiency & accuracy

5 rights of eMars

right patient, right medicaition, right dose, right time & right route

CPOE

computerized physician order entry

medication reconciliations

process of obtaining & updating an accurate list of all patient's medications

benefits of PHR

1. elimination of errors made by patients filling out , 2. Allows patients with health concerns to travel with less worry, 3. ensures the safety of health records

computer-based, stand-alone

downloadedor installed onto their computer

internet based, tethered

individuals are granted access to phr through an outside organization, like insurance or providers

internet based, untethered

individuals are granted access to phr through a web based application with a user name and password

Internet based, networked & interoperable

allows transfer of the patient's providers, insurance or pharmacies (does not ensure privacy & security)

DRS

Designated Record Set

What Designated Record Set includes:

protected health information and is maintained by a covered entity

ePHI

Electronic Protected Health Information

NPP

Notice of Privacy Practices

TPO

Treatment, Payment & Operations

what is Treatment, Payment & Operations?

conditions that protected health information can be released without consent from the patient

clearinghouse

companies that process health information

What is a covered entity (CE)?

health plans, providers & clearinghouses and HIPAA regulations apply

HUGN

Human Gene Nomenclature set

What is the Human Gene Nomenclature?

standards about the role of genes in bio-med research

clinical templates

progress notes made within the EHR

clinical vocabularies

standardized system of medical terminology

Current Procedural Terminology

system of classification for services & procedures used in the outpatient setting

Digital Imaging and Communications in Medicine

standardized system used to transfer information between imaging systems

arthr/o

joint

cardi/o

heart

carcin/o

cancerous, cancer

cephal/o

head

cerebr/o

cerebrum

cyt/o

cell

dent/I

teeth

derm/o

sin

electro/o

electrical activity

enter/o

intestines

fet/o

fetus

gastr/o

stomach

rhin/o

nose

sarc/o

flesh

thromb/o

clotting

ur/o

urinary tract

-al

pertaining to

-algia

pain

-dynia

pain

-ectomy

excision, removal

-emia

blood condition

-genic

produced by, pertaining to producing

-globin

protein

-itis

inflammation

-oma

tumor, mass swelling

-osis

condition, usually abnormal

-pathy

disease condition

-sis

state of; condition

Ante-

before, in front of

Anti-

against

brady-

slow

dia=

through, complete

end, endo

within

epi-

above, upon

hyper-

excessive, above more than normal

hypo-

deficient, below, under less than normal

peri-

surrounding, around

pre-

before

sub-

under, below

-ectomy

excision

-graphy

process of recording

-metry

process of measurement

-scopy

a visual examination

-stomy

a new opening

-tomy

incision

-tripsy

process of crushing

musculoskeletal

muscle, bones, joints, bone marrow

function of musculoskeletal system

support, movement, protection

integumentary

skin, hair, nails

function of integumentary system

protection

gastrointestinal

stomach, intestines

function of gastrointestinal system

nutrition

urinary

kidneys, bladder, ureters, urethra

function of urinary system

elimination of nitrogenous waste

reproductive

ovaries, testes

function of reproductive system

reproduction

blood/lymphatic

blood cells

function of blood/lymphatic system and cardiovascular system

transportation

function of immune system

protection

cardiovascular

heart, vessels

immune system

lymph glands

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