49 terms


Final Study tools
Where does the data that appears
in the patient management tab come
Previous patient visits or previous patient
Why would clinicians use trending of
lab results and what type of results
can be graphed?
To compare the change of certain test components over a period of time. Results
with numerical values can be graphed.
Describe the benefits of having patients
entering their own symptoms and
Only the patient has the information about
what symptoms were present at the outset
of the illness. Only the patient has the information about the outcomes of the medical
treatment of those symptoms. The patient is
also the source of past medical, family, and
social history. Patient-‐entered data is a
more accurate reflection of a patient's complaints. Patients who can review their
histories are better prepared for the visit.
Why are childhood immunizations important?*
Immunization slows down or stops disease
outbreaks. Vaccines prevent disease in the
people who receive them and protect those
who come into contact with unvaccinated individuals. Through childhood immunization, we are now able to control many infectious
diseases that were once common in this
country, and from which many children
List at least three ways that codified
data in the EHR can be used to manage and prevent disease.
Disease management
Graphic analysis
Preventative screening *
Interactive alerts
Describe a problem list and provide at
least two reasons why clinicians use
a problem list.
A problem list is an up-‐to-‐date list of the
diagnoses and conditions that affect a particular patient's care. Clinicians might
use a problem list for any two of the following reasons: Easy to see the active problems for
a patient, and also view the history of problems. Most clinical information recorded in
the chart will be related to one or more
problems. Everyone who touches the patient
knows what conditions are present. Problem
lists are used to track both acute and chronic
conditions. Such lists help the clinician to remember to follow up on conditions from previous visits. Maintaining a problem list
is a requirement for accreditation by JCAHO.
Describe how to create a flow sheet
from a form.
While on the form tab, with a form loaded, click
on the button labeled "FS Form."
What does it mean to cite a finding
and how would you do it from a flow
Citing from a previous exam note means to
bring a finding into the current encounter, usually as a follow-‐up to a previous visit.
Click the Cite button on, and then click on*
a single finding in one of the columns, or click
the date at the top of the column.
What are "evidence-‐based" guidelines?*
"Evidence based" guidelines are ways to analyze scientific evidence from current research and studies to determine the
effectiveness of preventive services.
Name at least three external sources of
data for populating the EHR.*
Electronic lab orders and results
Vital Signs
Digital spirometers
Ultrasound equipment
Holter monitors
In-‐house LIS systems
What is a growth chart percentile?
Curved lines representing what percentage of
the reference population the individual would
equal or exceed at a given size for age.
List the four components of the HIPAA
Administrative Simplification Subsection.
Transactions and Code Sets
Uniform Identifiers
Security *
Compare the difference between HIPAA Consent and HIPAA Authorization.*
Authorization requires the patient's permission to disclose PHI; signed consent is optional.
The patient gives consent for the provider
to disclose PHI for purposes of treatment, obtaining payment, and operation of the
healthcare facility by acknowledging receipt
of a copy of the office privacy policy.
Does a provider need the patient's
consent to share PHI with an authorized
government agency?
Name the Covered Entities under
Healthcare providers,health insurance plans,
clearinghouses. *
Name some advantages of a PHR.
Enables patients to better manage their health ***********
by maintaining their own electronic copies of
their health records. Available whereever the
patient is treated. The PHR is secure and
private, and is owned and managed by the
patient. Patients control who can access their
Give an example of a specialty that might use annotated drawings in an
encounter note.*
Ophthalmology and dermatology were examples provided in the textbook. (Allow
for other reasonable answers, such as
cardiovascular, obstetrics, orthopedic,and
general surgeons.)
How is the Internet changing healthcare?* Give examples of changes.
People shop for doctors online; insurance
companies provide online participating provider lists; physician specialty associations and state and local medical societies all
offer websites that help patients locate
a provider near them. Patients and clinicians
are both using the internet for research. *Clinicians can obtain decision support and
continuing education online*Patients can
schedule appointments, complete pre-‐ appointment questionnaires, and view lab
results online and maintain their own personal
health records (PHR). E-‐visits allow patients
to be treated by their regular doctor for nonurgent matters online.
List the three criteria of an Electronic
Message integrity, nonrepudiation, and user
Name the key components of an
E&M code.*
History, Examination, Medical Decision Making.
Where are "bullets" used in E&M
In the Examination component. They refer to
specific items in various body systems marked
with a typographic character called a "bullet"
in the CMS guidelines.
Information protected by the Security
Electronic Signature standard*
Calculation for height/weight ratio
Procedure code set
Three vaccines
Enforces HIPAA Privacy Rule
Element of a patient exam
Method of Internet Security
Explain the difference between an EHR
nomenclature and a billing code set.*
EHR nomenclatures differ from billing codes
because they are designed to codify the details
and nuances of the patient-clinician encounter*. Billing codes are designed to
represent the exam, service, or a medical
Which screen do you use to set the
reason for the visit?
The New Encounter window.
How do you enter Vital Signs?
The textbook teaches students to enter Vital
Signs using the Vital Signs form. They also
used a Short Intake Form that included Vital
Signs. Another acceptable answer would
be: Vitals Signs are entered (in this text) through a Form.
How do you load a list?
Click on the button on the toolbar labeled Lists.
This invokes the List Manager window. Highlight the desired List and click the button
labeled "Load List." (Another acceptable
answer: From the List Manager window.)
Review of System
History of Present Illness
Diagnosis or Assessment
Head, Ears, Eyes, Nose and Throat
Upper Respiratory Infection
What Entry Details field is used with
a finding to indicate a "possible" diagnosis?
What month and year is the United
States scheduled to begin using ICD-‐10?
October 2013.
Name at least three things that are
checked by a DUR alert system.
A conflict with any drug the patient is already
taking. Ingredients that make up the drug are
checked against the ingredients of current medications to see if they conflict or would hinder the effectiveness of the drug. Drugs
are checked for duplicate therapy, which
occurs when a patient is taking a different
drug of the same class and would have the
effect of an overdose. Allergy records are
checked for food and drug allergies that would
be aggravated by the new drug. The
patient's diagnosis history is checked to see
if the patient has a medical condition thatthe
drug would negatively affect. A patient education alert is created when the drug
might be affected by certain foods or
alcohol interactions. If the Sig has been
entered at the time of the DUR, then it is
also checked to see if it matches recommended guidelines for the drug. Too much, too little, too many days, or too
many refills could cause overdosing, underdosing (causing the drug to be ineffective), or abuse.
Increases or decreases the quantity of findings
displayed on a List (or in the Nomenclature pane.)
Invokes Prescription Writer (Another acceptable answer: Orders medications)
Invokes the search prompt dialog window Searches for a word or phrase Quickly
locates all findings in the nomenclature matching the search word
Automatically set all the findings (that are
not already set) to "normal."
The ROS button toggles off and on. When it
is On, symptom findings are recorded in
the Review of Systems section of the encounter note. When it is Off, the symptom
findings are recorded in the History of Present
Illness section of the encounter note.
Prompt with current finding; dynamically generates a list of findings that are medically
related to the finding that was highlighted at
the time the Prompt button was clicked.
Adds the prefix "Ordered" to a test finding.
(Another acceptable answer: Orders tests)