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211 terms

Certified EHR specialist exam

EHR certification exam
STUDY
PLAY
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
Bi/o
life
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
respiratory
lungs, bronchi, trachea
function of respiratory system
delivers oxygen to cells
nervous/behavioral
brain, nerves, mind
function of nervous system
receive/process information
endocrine
pancreas, thyroid
function of endocrine system
effects changes through chemical messengers
Anterior (ventral)
front surface of body
posterior (dorsal)
back side of body
deep
away from the surface
proximal
near the point of attachment to the trunk or near the beginning of a structure
distal
far from the point of attachment to the trunk or far from the beginning of a structure
inferior
below another structure
superior
above another structure
medial
pertaining to the middle or nearer the medial plane of the body
laterial
pertaining to the side
supine
lying on the back
prone
lying on the belly
No ROMq
most synarthroses are immovable joints held together by fibrous tissue
ROM
range of motion
limited ROM
amphiathroses are joints joined together by cartilage that is slightly movable
full ROM
diathroses are joints that have free movement (synovial joints)
synovial joints
free moving joints, surrounded by joint capsules
extension
to increase the angle of a joint
flexion
to decrease the angle of a joint
abduction
movement away from the midline
adduction
movement towards the midline
supination
turning the palm or food upward
pronation
turning the palm or food downward
dorsiflexion
raising the foot, pulling the toes toward the shin
plantar flexion
lowering the foot, pointing the toes away from the shin
eversion
turning outward
inversion
turning inward
protraction
moving a part of the body forward
retraction
moving a part of the body backward
rotation
revolving a bone arounde its axxis
comminuted fracture
the bone is crushed and or shattered
compression fracture
bone collapses on itself
Colles fracture
break of the distal end of the radius (occurs from breaking a fall)
complicated fracture
the bone is broken and pierces an internal organ
impacted fracture
bone is broken and the ends are driven into each other
hairline fracture
minor fracture, thin line not completely through the bone
greenstick fracture
partially bent and partially broken bone
patholic fracture
fracture occurring spontaneously as a result of disease
Salter-Harris fracture
fracture of the epiphyseal plate in children
sprain
injury to a joint involving the soft tissue
strain
lesser injury, result of overuse or overstretching
dislocation
when a bone is completely out of place
subluxation
bone is partially out of joint
Albino
deficient in pigment
collagen
structural protein found in the skin and connective tissue
melanin
major skin pigment
lipocyte
a fat cell
macule
discolored, flat lesion (freckles, tattoo marks)
polyp
benign growth extending from the surface of the mucous membrane
fissure
groove or crack like sore
nodule
solid, round or oval elevated lesion more than 1 cm in diameter
ulcer
open sore on the skin or mucous membranes
vesicle
small collection of clear fluid blisters
wheal
smooth, slightly elevated, swollen area that is redder or paler than the surrounding skin
alopecia
absence of hair from areas where it normally grows
gangrene
death of tissue associated with loss of blood supply
impetigo
bacterial inflammatory skin disease characterized by lesion, pustules and vesicles.