Practice test for spiral bound book notes
Terms in this set (63)
EHR/EMR software is more comprehensive than practice management software because it?
Includes clinical documentation
A patient is entered into the patient list how many times?
The process of moving a patient from appointment making through check-out is called?
One factor that might contribute to slow acceptance of EHRs is?
What is an illustration of clinical information collected through an EHR?
plan of care
The acronym HIE stands for?
health information exchange
An advantage of using screen-based data collection tools is that the layout of the information on the screen can be?
Who defined the eight core functions of an EHR?
The institute of Medicine defined the eight core functions of an EHR.
In a physician's office, patient data collection begins when?
When the patient calls to make an appointment
When patients are finished with their encounter at a hospital, they?
If a hospital uses information gathered through their EHRs to justify the purchase of state-of-the-art equipment to improve patient care, they are?
engaging in meaningful use
What roles might be held by a healthcare administrator?
A health care administrator would serve in an executive position.
What is the difference between a medical assistant and an office administrator?
Medical assistants provide patient care and manipulate the information on a patient's health record, while an office administrator oversees staffing and administrative functions of an entire office facility.
In the past, physicians marked the location of a patient's pain by drawing on a picture of a body. With advantages of EHRs, what are they now able to do?
Computerized models are extremely specific in terms of locating pain
What do PACS allow providers to do?
PACS allow users to view images, such as x-rays, remotely for use in clinical decision-making
Can a patient's previous health records be used as a source of data? explain your answer.
Yes, a patient's prior health records can be used as a source of data. It can be used to help with assessment and forming of treatment plans
What are two ways that identifying information is collected from a patient?
A patient can return a completed form to the office, or verbally respond to a healthcare professional's questions
Knowing that Jim Smith had a heart attack when he was 53 is an example of?
Define the roles of six healthcare professionals involved in EMR use:
-Health care administrator oversees organization of departments
-Director of HI department- focuses on health information sector of facilities
-RHIA serves management capacity within HIT departments
-RHITs serve as health information staff
-MA works in an outpatient setting
-Office manager ensures outpatient facilities are using EMRs correctly
Explain the difference between data and information, and give an example of each
Data is a single fact, while information is a collection of facts. Examples will vary.
List four types of histories entered into a patient's electronic record:
If someone has the letters "RHIA" after his or her name, what does that mean?
Registered Health Information Administrator
Explain the purpose of a Regional Extension Center (REC)
A REC oversees the selection, implementation, and maintenance of EHRs in a given geographic region of the United States.
Incentives are a significant part of the HITECH act. Discuss the advantages and potential disadvantages associated with using incentives as a tool for implementing EHRs.
Some advantages might be increased compliance with regulations, quicker implementation, speedy integration. Some disadvantages could be an increase in errors due to quick ramping of the system, falsification or negligence in data reporting in order to receive incentives.
A physician's office and a hospital employ different terminology and process flow when maintaining records and monitoring patient flow. Why is there no set protocol that is used by all healthcare settings?
Because each setting has different priorities, levels of protocol, and escalation of issues. Therefore, each setting needs to employ terminology and language that is specific to their points of care.
Think about the five main objectives of an EHR. Which of the five do you feel would be most useful for care providers? For patients? For office managers? Explain your answers.
Overall, care providers will probably benefit most from the quality/coordination of care objectives and the legal protection objective, patients will probably benefit from the legal protection objective, office managers will probably cite the filling, billing, and insurance claim objectives.
__________ data includes demographic data?
Anna Jacobs presented to the ER of County Hospital three times in the past year. She will appear in County's MPI:
Once (a patient only appears in a facility's MPI one time, no matter how many individual visits they have)
Before a patient can be treated at a healthcare setting, she must be?
registered (a patient needs to be registered before receiving and healthcare services)
How long should a facility's Master Patient Index be kept?
What is part of a patient's administrative information found on a registration form?
Patient demographic information should be verified?
at each visit (it is important to verify patient information each time they come in for a visit
What is part of the appointment scheduling feature of PrimeSUITE?
Accountable Care Organizations rely on EHR?
data (Accountable Care Organizations rely on the data gathered through an EHR)
Editing a patient's mailing address is accomplished by using?
In a hospital's health information department, patient records are most often filed by?
medical record number
Recording a patient's previous or married name might help with?
An insurance claim may be denied if the receptionist fails to?
enter all data correctly
Patient check-in is?
important for efficient patient tracking
Discuss why administrative data such as race, ethnicity, and preferred language might need to be reported to satisfy meaningful use requirements.
These pieces of information might be analyzed to ensure that a practice is not discriminating or showing prejudice toward a specific group of people, to ensure that all patients are being served equally and that a practice's patient population is representative of the demographic area of it's location.
An on-screen item of dat is known as a?
field (a field refers to an on-screen item of data)
PrimeSUITE allows you to note discrepancies in the ___________ box.
What is NOT a required patient history?
Birth histories are not required, but family, social, and surgical histories are.
who will benefit from thoroughly completed paper forms?
Care providers, patients, and receptionists.
The patient's ___________ history could possibly help predict a future health condition.
illnesses or conditions that run in a patient's family may predict future health conditions for a patient
What is an acceptable way of gathering a patient's history?
A patient's histories are gathered through an interview process.
What information should you see on all forms in a patient chart?
name, date of birth, and medical record number
A patient's past surgical history includes the
approximate date of the procedure
What history includes a patient's exercise regimen?
A patient's vital signs are entered via PrimeSUITE's what screen?
What piece of information might be included multiple times on a form?
A patient's past surgical history includes the?
approximate date of the procedure
Any discrepancies in patient information need to be?
documented (It is critical to document any discrepancies in patient information)
Why, in the age of EHRs, is patient information still gathered mainly through the use of paper forms?
Overall, paper forms save time because patients can complete them prior to a visit and they will allow a paper record of information.
Why might so many patient histories need to be taken?
Each history serves a different purpose, and together they show a patient's health.
As an office manager for a large healthcare practice, you have been asked to design a new patient intake form. Sketch out your form's layout, keeping in mind the best practices discussed in the chapter.
Your form should keep logical information together, eliminate repetitive information, and have a proper title.
What is an example of history of present illness?
Duration of illness
Notes about a prescription ordered for a patient would appear in the _____________ section of a SOAP note.
PrimeSUITE has the capability to _____________ the status of an order.
Information gathered during a provider's physical exam would appear in the ________ section of a SOAP note.
There must be a ___________ to perform any tests or treatments.
care provider request
What element of a HPI are collected at a visit?
only those that apply to the patient's chief complaint
Meaningful use regulations require the keeping of an up-to-date