CEHRS Exam Study notes
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Central Georgia Technical College *
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Course
2370
Subject
Medicine
Date
Jan 9, 2024
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Electronic Health Record (EHR)
computerized lifelong record health care record w/ data from all sources
technology that intertwines health info from a variety of sources
every encounter an ind has w/ the health care system is documented (labs, scripts, ER visits,
etc...)
New position created by EHR
Clinical Analyst
Health Information Technician * Records and info coordinator
What setting may a CHERS work?
Dr office labs
Ref Labs
Urgent Care Centers
Nursing Home Facilities
Wellness Clinics
Hospitals
Why were chances in technology made?
from realization that medical records were not meeting the needs of dr's & pt's. Increase in
errors, rising health care costs and missing link in a pt's coordination of care.
Medical Errors
-among most common causes of death, occur b/c:
*Lost medical records
*Miscommunicated pt request/messages
*Unreadable info due to poor handwriting
*Mislabeled lab specimens
many of these errors could be overcome if info tech were applied throughout healthcare system.
What potential does HIT have?
improve the quality of care and possibly reduce the number of deaths attributed to medical errors
What was HIPPA designed for?
enacted in 1996, designed to protect pt's private health info, ensure health care coverage when
workers change or lose their jobs, and uncover fraud and abuse in health care systems.
HIPPA requires the use of electronic rather than paper ins claims?
True
Standards
commonly agreed upon specifications, are what helped establish the requirements necessary for
agencies to follow
When did Pres Bush recommend the use of Health Information Technology (HIT)? What was the
goal? Who was established to meet this goal?
In 2004, set 10 yr goal for all americans to be using EHR's, and established the OFFICE OF
NATIONAL COORDINATION FOR HEALTH INFORMATION (ONCHIT) to meet this goal.
HITSP?
department/organ that identified standards for exchange of health info
CCHIT?
developed certification criteria for EHR software
What does the Nationwide Health Information Network (NHIN) provide?
links medical records across the country
What 8 core functions does the Institute of Medicine suggest an EHR should include?
1) Health Info and data elements
2) Results Management
3) Order Management
4) Decision Support
5) Electronic communications and connectivity
6) Patient Support
7) Administrative Processes
8) Reporting and population management
Medical Record
an important business document
used to support treatment decisions
documents services provided
could also be used in court of law for evidence purposes
Electronic Medical Record (EMR)
computerized records of one dr's encounter w/ a pt over time including medical history,
diagnosis, treatment and prognosis
What is the contrast between EMR's and EHR's?
EMR's reflect treatment of a pt by one dr as EHR reflects data from ALL sources that have
treated and ind
Personal Health Record (PHR)
maintained & owned by the pt, pt makes decisions whether to share contents w/ their dr.
Acute Care
most often refers to a hospital, treats pt's w/ urgent problems that cannot be handled in another
setting (hospital records keep track of time-limited episodes where dr charts reflect the ongoing
health of ind) **
Inpatient treatment
**
Ambulatory Care
refers to treatment w/o admission to hospital
What are the advantages of EHR's?
Safety
Quality of Care
Efficiency
Cost Reduction
Will the decision of going completely electronic have a huge impact on pt efficiency?
Yes
What is a Total Conversion?
method of converting medical records all at one from paper to electronic, may be costly, but it
allows all pt data to be converted at once while office can still service pt's **
outsourced to an
external company
**
What is Incremental Conversion?
gradual change to electronic records. Advantage of this type of change are lower cost and a
smoother transition due to less of an impact on the office. Disadvantages are that paper still
needs to be used and not all pt data is available. **
usually begins w/ pt's w/ scheduled appt
***
What is Hybrid Conversion?
using a combination of paper and electron form of data. No matter what form is used dr still need
to enter progress notes (most dr choose dictation/transcription process) **
some may be
outsourced, others in house
*
What are clinical templates and what do they allow?
structured form (progress notes) that allows dr's to document pt encounters into an EHR, once it
is entered it must be INTEROPERABLE: must be able to exchange info and use it in a
meaningful way, therefore clinical standards are important to the details of pt info
Clinical Standards
-ensure consistency, reliability and safety
Types of Clinical Standards
-CLINICAL VOCABULARIES- set of common definitions for medical terms, they ease
communications by decreasing ambiguity
-SNOMED-CT- clinical vocabulary designed to encompass all terms used in medicine
-LOINC- terms and codes used for electronic exchange of lab results and clinical observations
-UMLS- thesaurus database of medical terms
What are CLASSIFICATION SYSTEMS?
they organize terms into categories for easy retrieval, they are used for billing and
reimbursement, statistical reporting and admin functions
ICD-9 and ICD-10
International Classification of Disease-standard developed by World Health Organization
(WHO) contains diagnosis codes that are used in all health care settings.
ICD-9-CM
DIAGNOSIS USAGE: Inpatient & Outpatient
*Number of characters: 3-5 alphanumeric
*Number of Codes: 13,000
PROCEDURE USAGE: Inpatient*
*# of characters: 3-4 numeric
*# of codes 4,000
ICD-10-CM
DIAGNOSIS USAGE: inpatient & outpatient
*# of characters: 3-7 alphanumeric
*# of codes: 120,00
PROCEDURE USAGE: none
ICD-10-PCS
DIAGNOSIS USAGE: none
PROCEDURE USAGE: inpatient
*# of characters: 7 alphanumeric
*# of codes: 200,000
CPT
Current Procedural Terminology- list of descriptive terms and identifying codes for reporting
medical services and procedures performed by health care professionals in outpatient setting,
developed and maintained by American Medical Association (AMA)
CPT Code Ranges
EVALUATION & MANAGEMENT (E&M): 99201-99499 (go to dr feeling 99% leave getting
high five)
ANESTHESIA: 00100-01999 (knocked out, always begin w/ 0)
SURGERY: 10021-69990 (want to feel 100%, begins w/ 1)
RADIOLOGY: (RPM, R=7, begins w/ 7)
PATHOLOGY AND LABORATORY: 80047-89356 (RPM. P=8, begins w/ 8)
MEDICINE: 90281-99607 (RPM, M=9, begins w/ 9)
HCPCS
Healthcare Common Procedure Coding System- level II, national codes, contains codes for
products, supplies, and certain services not included in CPT. Codes are maintained by Center for
Medicare and Medicaid Services (CMS)
Messaging Standards
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-make it possible to transfer data from systems such as lab or pharmacy system, play crucial role
in interoperability among info systems
EX: HL7, DICOM, NCPDP AND IEEE1073
Health Level 7 (HL7) Messaging Standards
(messaging standard used to send data from one application to another)-scheduling, medical
record & image management, pt administration, observation reporting, financial management,
public health notification, and pt care
**demographics
**units of measure
**Immunizations
**Clinical encouncters
**Text based reports
Digital Imaging & Communications in Medicine (DICOM) Messaging Standards
image info to workstations (x-rays, nuclear medicine) **
standards that enable info exchange
between imaging systems
**
National Council for Prescription Drug Programs (NCPDP) SCRIPT Messaging Standards
used for retail pharmacy transactions **
standard for exchanging prescription info
** HIPPA
requires use in retail pharmacies
The institute of Electrical and Electronics Engineers 1073 (IEEE1073) Messaging Standard
standard that provides communication among medical devices at pt's bedside (device-device
connectivity)
Logical Observation Identifiers Names and Codes (LOINC) Clinical Vocabulary
contains laboratory results names, Interventions/procedures (Part A): Lab test order names
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) Clinical Vocabulary
contains lab results contents, interventions/procedures (Part B): nonlaboratory,
diagnosis/problem list. anatomy
Verbal Communication
use of the language or the actual words spoken, key components are sound, words, speaking and
language.
Nonverbal Communication
is the use of eye contact, body lang, facial expressions, or symbolic expressions to communicate
a message
Respect
essential part in the process of communication w/ coworkers, pt's & visitors. Following steps to
create a comfortable environment:
*refrain from making jokes or negative remarks that demean the abilities, skills or aspects of
coworkers
*be patient & respectful when speaking w/ a caller that does not speak English clearly
What clinical information must be included in the patients chart?
-Vital Signs: measurement of the pt's temp, respirations, pulse and blood pressure
-Chief Complaint: A verbal account made by the pt's describing their problem
-Progress Notes: Documentation of the care delivered to a pt along w/ necessary info regarding
their diagnosis and treatment
-Past Medical History: Info regarding the pt's past medical problems, conditions or surgeries
-Family History: Info regarding the medical problems of pt's family
-Social History: Info regarding the pt lifestyle such as smoking, drinking, habits, relationship
status, & sexual history
-Allergies- List of the pt's allergies as well as their reactions to each one
-Medication List: Info regarding the dosage & freq of the pt's meds
-HPI (History of Present Illness): compilation of info regarding all aspects of pt's present illness
-ROS (Review of Systems): inventory of body systems in which the pt reports signs or
symptoms he or she is currently having or has had in the past
-Diagnosis & Assessment: dr's conclusion regarding the cause of the pt's problem
-Plan & Treatment: dr's recommended plan of action to cure or manage the pt's condition
Patient Flow
1) Appt scheduling, info collection
2) Pt check in, payment collection
3) Rooming, measurement Vital Signs, Pt Exam, and documentation
4) Pt checkout
5) Coding & Billing, reviewing test results
Clinical Tools
EHR's allow dr's the ability to access research, detail natioanl treatment and makes pt's w/
chronic diseases easier to manage. EHR's also allow dr's to:
Order test
Order Meds *Send
scripts directly to pharmacy. It also has features that check for medication contraindications and
errors
EHR'S and Billing and Coding
Most EHR's have features that automate the coding process, though each EHR these features
may vary, these codes are checked for accuracy by a coding specialist. COMPUTER ASSISTED
CODING works in a variety of ways, some may assign codes based on keywords, other analyze
words/phrases and sentences. The integration of automated coding w/ the billing system
facilitates claims processing
Must every service submitted for payment be documented in the pt's medical record?
YES, in order to be reimbursed, providers must document each service provided to the pt
Decision Support Tools
make the latest clinical info available at the point of care
some of the most common features inc: access to clinical info while making a diagnosis, ID'ing
pt's @ risk for a specific disease and adherence to guidelines if pt monitoring is necessary.
Clinical Tools will also do the following:
Screen for illness and disease
Identify at risk pt's *Aid
w/ disease management
What are clinical guidelines?
descriptions of recommended pt care for a given condition based on the best available scientific
evidence. Guidelines are based on evidence and are developed by experts in the field.
Medication Errors
errors in prescribing medicine harm almost one million americans per yr. These errors range
from prescribing a drug that interacts w/ drugs that the pt is already taking to dispensing the
wrong med due to poor handwritting
E-Prescribing
the ability to e-prescribe is a feature of most EHR programs. One of the main advantages is it's
ability to quickly perform safety checks, EHR programs will send alerts for potential prescription
problems.
EHR in the Hospital
EHR in a hosp is extremely important to pt care. EHR compiles data from multiple clinical
systems and provides a single source of info about that particular pt. EHR will also capture and
store info about the pt care. It will assist in managing transactions such as: medicine prescribed,
test ordered/results, and ultimately improving the quality of pt care.
Are hospital information systems complex?
Yes
What are factors that affect the care the patient receives in a hospital?
-financial aspect of a pt's stay
-lab test ordered
-pharmacy info
-picture archiving
-radiology info
-clinical info
(all contribute to a pt's overall care in a hospital)
What are the primary benefits of a Hospital EHR?
-Unlimited access to pt's ino
-Decreased waiting time for medication delivery as well as test results
-Increased efficiency and accuracy in overall pt care
Computerized Physician Order Entry (CPOE)
an application used by dr's and other healthcare providers to enter pt care info EHR's w/ the
CPOE feature also provides support tools that result in improved care and pt outcomes
Electronic Medication Administration Records (eMars)
work w/ the CPOE system to increase pt safety by electronically tracking medication
administration.
The 5 rights to medication administration (eMars)
1) the right pt
2) the right medication
3) the right dose
4) the right time
5) the right route (oral or intravenous)
Order Sets
pre-defined groupings of standard orders for a condition, disease or procedure. These order sets
make it easier to deliver quality care by eliminating errors and providing easy access to clinical
content.
Adverse Drug Event (ADE)
side effects or complications from medications
Medication reconciliation
the process of obtaining and updating an accurate list of all a pt's meds, is vital to the care of pt's
Personal Health Record (PHR)
the compilation of the various componets of a pt's lifelong medical history into an electronic
format, may incl personal history, allergies, past immunizations, previous surgeries and much
more. While the pt is usually responsible for the creation and maintenance of their personal
record, they have the option to share the info w/ their provider. Educate pt's as well as those
involved in their healthcare. Make it easier to monitor their health, record observations, and
follow plan recommendations
Does the PHR replace the legal records of any of the patients providers?
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NO
Benefits of the Personal Health Record
PHR is proof that the medical system is evolving to fit the needs of the fast-paced, constantly
changing lifestyle that many of us are accustomed to. As consumer begin to make use of this
resource, bulky, time consuming forms will be a thing of the past.
What are a few of the "perks" of the PHR?
-elimination of errors made by pt filling out forms that request info the pt might not have access
to
-allows pt w/ health concerns to travel w/ less worry since their records can be accessed from any
location
-ensures the safety of health record located in healthcare facilities in the event of a natural
disaster
Computer-based, stand alone PHR
Ind gain access their PHR using a software program that has been downloaded or installed onto
their computer. Info from this type of health record is transferred to a portable memory device in
order for it to be accessed from a diff location
Internet based, tethered PHR
Ind are granted access to this PHR through an outside organization, such as ins co or pt's dr.
Unlike other versions of PHR, users of an internet based PHR may have limited editing
capabilities. Ownership of this version of the PHR is maintained by the organization that
provides access to the user. Not a true PHR. May include Patient Portals
Internet based, untethered PHR
Ind are granted access to their PHR through a web based app. Upon the creation of a username
and password, the user is able to create and update info as needed
Internet based, networked and interoperable
a networked PHR allows the transfer of info of the pt's dr and of other health care org such as ins
co and pharmacies. A networked PHR is continually updated. One big disadvantage of this PHR
is that it does not ensure complete privacy and security.
HIPPA
2 parts: Title I- health ins reform; Title II- provides rights for the transfer of electronic health care
data. Administration and Simplification Standards (Title II) put privacy and security mechanisms
in place to ensure personal health info is kept confidential
Do HIPPA regulations apply to everyone?
no, only those who provide health care in the normal course of business and electronically
transmit info. (COVERED ENTITIES, CE-health plans, providers and clearinghouses are
covered entities.
Health Plan
ins plan that provides or pays for medical care
Providers
people or organizations that furnish, bill, or are paid for health care in the normal course business
Clearinghouse
companies that process health information and execute electronic transactions
Designated Record Set (DRS)
any item, collection, or grouping of info that includes PHI and is maintained by a CE
Electronic Protected Health Information (ePHI)
PHI that is created, received, maintained or transmitted in electronic form
Notice of Privacy Practices (NPP)
document that describes practices regarding the use and disclosure of PHI
Protected Health Information (PHI)
individually identifiable health info that is transmitted or maintained by electronic media or in
any other form or medium
Treatment, Payment and Operations (TPO)
conditions under which PHI info can be released w/o consent from the pt
What is considered PHI?
-name -address -names of relatives/employers -SS# -phone/fax # -email address -health plan ID#
-Account # -fingerprints -website address -medical record # -Serial # of vehicles -Photo's
Does the release of any info require authorization?
Yes, except TPO purposes
General Authorization
typically required for uses other than TPO
Specific Authorization
required for info about HIV, STD's and drug and alcohol abuse
Rights of Individuals
Notice of Privacy Practices describes the CE practices regarding the use and disclosure PHI. The
CE must document when the pt receives such notice. Ind also have right to access and inspect a
copy of their PHI, request an amendment of record, request restrictions on uses and disclosures
of PHI and file a compliant about a violation w/ the Office of Civil Rights
Clinical Templates
progress notes made w/in the EHR
Clinical Vocabularies
A standardized system of medical terminology
Current Procedural Terminology (CPT)
system of classification for services and procedures used in the outpatient setting
Digital Imaging and Communication in Medicine (DICOM)
standardized system used to transfer info between imaging systems
Health Information Technology (HIT)
use of technology as a resource to manage pt health care info
Health Level Seven (HL7)
messaging standard used to transfer data between applications
Healthcare Common Procedure Coding System (HCPCS)
system of classification for certain services and procedures not listed in CPT manual
International Classification of Diseases, Ninth Revision (ICD-9-CM)
standardized categorization of diseases
Institute of Electrical and Electronic Engineer 1073 (IEEE1073)
standardized system used to provide communication between medical devices
Logical Observation Identifiers Names and Codes (LOINC)
clinical vocabulary including terms used in the electronic exchange of lab results and clinical
observations
National Council for Prescription Drug Program (NCPDP)
standardized system used to transfer prescription info
Systematized Nomenclature of Medicine Clinical Terms (SMOMED-CT)
clinical vocabulary including medical, procedural and diagnostic terms
Unified Medical Language System (UMLS)
electronic resource containing various medical terms
How is medical terminology broken down?
Into word roots, prefixes,, suffixes and combining vowels and forms. Word roots, or base words,
are the foundation of the healthcare term. A SUFFIX is a word ending, a PREFIX is a word
beginning and a combining vowel (usually an o) links the root to the suffix or to another root. the
combining form is word root plus the appropriate combining vowel
Combining Forms and their Meanings
...
Arthr/o
Joint
bi/o
life
cardi/o
heart
carcin/o
cancerous, cancer
Cephal/o
head
Cerebr/o
cerebrum (largest part of the brain)
Cyt/o
cell
dent/i
teeth
derm/o
skin
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
Some suffixes of their Meanings
...
-al
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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
Some Prefixes and their meanings
...
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
Suffixes used to describe therapeutic interventions
...
-ectomy
excision
-graphy
process of recording
-metry
process of measurement
-scopy
a visual examination
-stomy
a new opening
-tomy
incision
-tripsy
process of crushing
Body Structure and Directional Terminology
...
Musculoskeletal
Function: support, movement protection
Organs: Muscles, bones, joints, bone marrow
Integumentary
Function: protection
Organs: skin, hair, nails
Gastrointestinal
Function: nutrition
Organs: stomach, intestines
Urinary
Functions: elimination of nitrogenous waste
Organs: kidneys, bladder, ureters, urthra
Reproductive
F: reproduction
O: ovaries, testes
Blood/Lymphatic
F: transportation
O: blood cells
Immune
F: protection
Cardiovascular
F: transportation
O: lymph glands, heart, vessels
Respiratory
F: delivers oxygen to cells
O: lungs, bronchi, trachea
Nervous/Behavioral
F: receive/process information
O: brain, nerves, mind
Endocrine
F: effects changes through chemical messengers
O: pancreas, thyroid
Transitional and Directional Terms
...
Anterior (ventral)
front surface of the body
Posterior (dorsal)
back side of the 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 of nearer the medial plane of the body
Lateral
pertaining to the side
Supine
lying on the back
Prone
lying on the belly
No ROM
most synarthroses are immovable joints held together by fibrous tissue
Limited ROM
amphiathroses are joints joined together by cartilage that is slightly moveable, such as the
vertebrae of the spine of the pubic bone
Full ROM
diathroses are joints that have free movement. Ball and socket joint (hip) and hinge joints (knees)
are common diathroses joints (synovial joints)
Synovial Joints
free moving joints are surrounded by joint capsules, many of the synovial joints have BURSAE-
sacs of fluid that are located between the bones of the joint and the tendons that hold the muscles
in place
Extension
to increase the angle of the joint
Flexion
to decrease the angle of the joint
Abduction
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movement away from the midline
Adduction
movement towards the midline
Supination
turning the palm or foot upward
Pronation
turning the palm or foot 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 around its axis
Fractures
broken bone, most occur as a result of trauma, however some diseases like cancer or
osteoporosis can also cause spontaneous fractures. Fractures can be classified as simple or
compound. Simple fractures do not rupture the skin, as compound fractures split open the skin
allowing for an infection to occur
Communicated Fracture
the bone is crushed and or shattered
Compression Fracture
the fractured are of bone collapses on itself
Colles Fracture
the break of the distal end of the radius at the epiphysis often occurs when the pt has attempted to
break his/her fall
Complicated Fracture
the bone is broken and pierces an internal organ
Impacted Fracture
the bone is broken and the ends are driven into each other
Hairline Fracture
a minor fracture appeas as a thin line on x-ray and may not extend completely through the bone
Greenstick Fracture
bone is partially bent and partially broken; this is a common fracture in children b/c their bones
are still soft
Pathologic Fracture
any fracture occurring spontaneously as a result of disease
Salter-Harris Fracture
a fracture of the epiphyseal plate in children
Sprain
a traumatic injury to a joint involving the soft tissue, the soft tissue includes the muscles,
ligaments, and tendons.
Strain
a lesser injury, usually the result of overuse or overstretching
Dislocaton
when a bone is completely out of place
Subluxation
bone is partially out of joint
Integumentary Vocabulary
...
Albino
deficient in pigment (melanin)
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 membrane
Vesicle
small collection fo clear fluid; blister
Wheal
smooth, slightly elevated, edematous (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 w/ loss of blood supply
Impetigo
bacterial inflammatory disease characterized by lesion, pustules, and vesicles
Question
Answer
WHAT DESCRIBES POINT OF CARE DOCUMENTATION?
THE PROVIDER DOCUMENTS THE
INFORMATION DURING THE PT
ENCOUNTER
WHAT IS AN EXAMPLE OF A STATIC REPORT?
BIRTH REGISTER FOR A
PARTICULAR DAY
AN EHR SPECIALIST IS CODING A CLAIM FOR A PT WHO FELL OFF A
CHAIR AND BROKE AN ARM. WHAT IS NECESSARY TO EXPLAIN THE
PT'S CONDITION IN FULL?
V-Y CODES
AN EHR SPECIALIST IS MONITORING CHANGES TO CPT CODES FOR
HIS FACILITY. THE CODE CHANGES ARE MANAGED AND UPDATED BY
WHOM?
AMERICAN MEDICAL
ASSOCIATION
A PROVIDER PERFORMS A CHEST XRAY BEFORE AND AFTER THE
PLACEMENT OF A CHEST TUBE. THE REPEAT PROCEDURE BY THE
SAME PROVIDER SHOULD BE CODED WITH WHAT?
MODIFIER
WHAT IS A BENEFIT OF DOCUMENTING A PT ENCOUNTER AT THE
POINT OF CARE?
IMPROVED PT OUTCOMES
DURING AN OFFICE VISIT A PROVIDER EXAMINES A BABY FOR DIAPER
RASH. WHAT TYPE OF CODE SHOULD THE EHR SPECIALIST USE TO
CLASSIFY THE TYPE OF VISIT?
EVALUATION AND MANAGEMENT
SERVICE CODES
THE GOVERNMENT RESEARCH STUDY HAS REQUESTED PT DATA.
WHAT ACTIONS SHOULD THE EHR SPECIALIST TAKE AFTER
CONFIRMING CORRECT AUTHORIZATION?
REMOVE PHI FROM THE DATA
STORING BACKUP DATA OR MEDIA IN AN OFFSITE LOCATION IS AN
EXAMPLE OF WHAT?
PHYSICAL SAFEGUARD
WHAT IS A FEATURE DECISION SUPPORT?
ALLOWS PT'S CARE TO BE
TAILORED TO PUBLISHED
GUIDELINES
AN EHR SPECIALIST IS ABSTRACTING INFORMATION FOR A STUDY
REGUARDING SEXUAL HISTORY OF TEEN PTS'. FROM WHAT
LOCATION SHOULD HE RETRIEVE THIS INFORMATION?
SOCIAL HISTORY
WHERE SHOULD THE EHR SPECIALIST ENTER INFORMATION FROM
VITAL SIGNS
EMR
WHAT IS THE NUMBER OF DAYS A PROVIDERS OFFICE HAS TO NOTIFY
PTS' THERE IS A BREACH TO MEDICAL RECORD SECURITY?
60 DAYS
WHAT MUST BE DOCUMENTED IN THE PT'S CHART FOR EACH
ENCOUNTER?
PROVIDERS SIGNATURE
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WHAT FORM MUST BE SIGNED TOHAVE A NON - COVERED
PROCEDURE PERFORMED?
ADVANCED BENEFICIARY NOTICE
THE SCHEDULING TEMPLATE WITHIN AN EHR SYSTEM CAN BE USED
FOR WHAT?
IDENTIFYING A LACK OF
RESOURCES THAT INTERFERS
WITH WORKFLOW
AN EHR BASED PROVIDERS OFFICE IS EXPANDING FROM 2
EMPLOYEES TO 5. WHAT ACTION IS THE MOST IMPORTANT TO
MAINTAIN PHI?
SET UP ROLE BASED CONTROLS
WHAT IS AN EXAMPLE OF MEANINGFUL USE?
A PROVIDER ELECTRONICALLY
EXCHANGES A PT'S LABORATORY
DATA WITH A MEDICAL SECIALIST
WHAT REASON SHOULD AN EHR SPECIALIST REPORT CONTAINING
INFORMATION ABOUT A PTS' COLONOSCOPIES AND FECAL OCCULT
BLOOD TESTS?
PERFORMANCE BASED PAY
IF A PT OWES A COPAYMENT. WHAT IS NEEDED TO ACCURATELY
COLLECT AND POST THEIR PAYMENTS?
ENCOUNTER FORM
WHAT IS THE BEST METHOD TO ENSURE RESTORATION OF EHR
DOCUMENTS?
BACKUP ALL DATABASE
INFORMATION
WHO GIVES BONUS TO PROVIDERS WHO SUBMIT THEIR USE OF
RECOGNIZED ONGOING PERFORMANCE MEASUREMENTS TO
MEDICARE?
PHYSICIAN QUALITY REPORTING
SYSTEM
WHAT IS A THREAT TO THE SECURITY OF INFORMATION IN AN EHR
SYSTEM?
ENVIROMENTAL FACTORS
WHAT FEDERAL ACT MANDATES PHYSICAL, TECHNICAL, AND
ADMINISTRATIVE SAFEGUARDS?
HIPAA TITTLE II
WHAT SHOULD A FACILITY INCLUDE IN ITS DISASTER RECOVERY
PLAN?
MAINTAINING A LIST OF IT
INFRASTRUCTURE
A PT PRESENTS TO A PROVIDERS OFFICE WITH A THIRD DEGREE
BURN ON HIS HAND FROM COOKING OIL. WHAT SHOULD AN EHR
SPECIALIST CODE FIRST?
CLASSIFICATION
WHAT IS A AUTOMATED BENEFIT OF USING AN EHR SYSTEM AT THE
TIME OF SERVICE?
PROVIDING DECISION SUPPORT
THE SCHEDULING TEMPLATE WITHIN AN EHR SYSTEM CAN BE USED
FOR WHAT?
IDENTIFYING A LACK OF
RESOURCES THAT INTERFERES
WITH WORKFLOW
WHAT IS NECESSARY FOR COMPUTER SYSTEMS TO EXCHANGE
INTREROPERABILITY
INFORMATION?
HOSPITAL A WAS RECOGNIZED FOR ITS EMPLOYEE SAFETY RECORD
AND HOSPITAL B HAS SET A GOAL TO ACHIEVE SIMILAR RESULTS.
THIS IS AN EXAMPLE OF WHAT?
BENCHMARKING
ACCORDING TO HIPAA WHAT IS CONSIDERED PROTECTED HEALTH
INFORMATION IN A MEDICAL RECORD?
PHOTOGRAPHIC IMAGES
WHAT IS AN ADVANTAGE OF USING CLINICAL TEMPLATES TO RECORD
PT ENCOUNTERS?
STANDARDIZES DOCUMENTATION
FORMATS
WHAT IS A PRIMARY DUTY OF AN EHR SPECIALIST AS THE
HEALTHCARE INDUSTRY IMPLEMENTS EHR REQUIREMENTS?
PROVIDING ONGOING TRAINING
OF EHR SOFTWARE
WHAT PART OF THE FINANCIAL INFORMATION SYSTEM WOULD BE
USED TO MANAGE AGING REPORTS BY GUANATOR OR CARRIER?
CLAIMS MANAGEMENT
A CLINICIAN ID RECORDING PT INFORMATION. WHAT INFORMATION
SHOULD A CLINICIAN DOCUMENT AS SUBJECTIVE?
CHIEF COMPLAINT
AN EHR SPECIALIST IS CODING FOR THE REIMBURSEMENT OF
DURABLE MEDICAL EQUIPMENT. WHAT CODE SET SHOULD BE USED?
HCPCS
WHAT PT RIGHTS DO HIPAA REGULATIONS ADDRESS?
TO ACCESS PERSONAL DIAGNOSIS
HISTORY
PROPER DOCUMENTATION TO SUPPORT REIMBURSEMENT OF
SERVICES IS THE RESPONSIBILITY OF WHAT PART OF THE HEALTH
CARE TEAM?
CLINCIAN
WHAT IS THE FIRST STEP OF THE SCANNING PROCESS?
DOCUMENT PREPARATION
WHAT IS A COMPREHENSIVE CLINICAL VOCABULARY DESIGNED TO
ENCOMPASS ALL TERMS USED IN HEALTH CARE?
SNOMED - CT
WHAT SAFEGUARDS INCLUDE AUTHENTICATION CONTROLS FOR A
PT'S PHI?
TECHNICAL
WHAT ALLOWS FOR ENTERING AND RETRIEVING DATA AND ITS
SPECIAL LANGUAGE FOR DATABASES?
SQL
WHEN PURGING INACTIVE HEALTH RECORDS, WHAT PIECE OF
INFORMATION MUST AN EHR SPECIALIST RETAIN?
BIRTH DATE
BILLED PROCEDURES AND SERVICES SHOULD BE SUPPORTED BY
WHAT?
MEDICAL RECORDS
WHAT IS THE MOST IMPORTANT REASON TO MAINTAIN AN
INVENTORY OF SOFTWARE USED IN THE OFFICE?
TO DETER UNAUTHORIZED
DUPLICATION
ANYONE WHO THINKS A HEALTHCARE PROVIDER HAS VIOLATED
HIPAA PRIVACY REGULATIONS CAN FILE A WRITTEN COMPLIANT
WITHIN 180 DAYS TO WHOM?
OFFICE FOR CIVIL RIGHTS
ACCORDING TO HIPAA THE USE OF CPT AND ICD-10 CM CODE SETS
ARE REQUIRED FOR WHAT?
ELECTRONIC DATA INTERCHANGE
WHAT IS THE CODING SYSTEM USED TO CONVERT WRITTEN
DIAGNOSES INTO NUMERIC FORM?
ICD
AN INSURANCE ADJUSTER REQUESTS A PTS' PROGRESS NOTES
FOLLOWING A MOTOR VEHICLE CRASH. WHAT SHOULD GUIDE THE
EHS SPECIALIST IN RELEASING THIS INFORMATION?
MINIMUM NECESSARY
WHAT SHOULD AN EHR SPECIALIST LOOK FOR AS PART OF A ROUTINE
CHART AUDIT?
ASSIGNMENT OF BENEFITS FORM
HEALTH LEVEL 7 (HL7) IS USED FOR WHAT?
TO EXCHANGE INFORMATION
BETWEEN SYSTEMS
WHAT DESCRIBES THE REFERENCE USED TO ENTER DIAGNOSIS
CODES IN A HOSPITAL SETTING?
ICD-10-CM
WHAT ELIMINATES ERRORS THAT ARISE FROM ILLEGIBLE
HANDWRITTING AND PROVIDES SAFETY CHECKS?
e-SCRIBING
WHAT COMPUTERIZED DOCUMENTS WOULD AN EHR SPECIALIST
GENERATE TO OBTAIN A PT SPECIFIC LIST OF PROCEDURES, SERVICES
AND SUPPIES WITH ASSOCIATED COSTS?
CHARGE DESCRIPTION FORM
WHAT SHOULD AN EHR SPECIALIST DO AFTER ENTERING DIAGNOSIS
AND PROCEDURAL CODES IN AN OFFICE USING AN EHR SYSTEM?
SUBMIT CLAIMS FOR
REIMBURSEMENT
WHAT CIRCUMSTANCE REQUIRES A PT TO GIVE SPECIFIC
AUTHORIZATION FOR THE RELEASE OF PHI?
MENTAL HEALTH TREATMENT
WHAT SHOULD AN EHR SPECIALIST RETRIEVE FROM THE PT'S
RECORD WHEN A PROVIDER REFERS THE PT TO A SPECIALIST?
INSURANCE INFORMATION
WHAT STEP SHOULD AN EHR SPECIALIST TAKE WHEN PREPARING A
PT'S INFORMATION FOR REVIEW AT AN INTERNAL CANCER
COMMITTEE MEETING?
REMOVE THE MEDICAL RECORD
NUMBER
WHERE CAN AN EHR SPECIALIST FIND DOCUMENTATION TO VERIFY
THE TIME OF A MEDICATION ADMINISTRATION?
MAR
A PROVIDER'S OFFICE IS USING CODING SOFTWARE WITH THE
ABILITY TO RECEIVE UPDATES TWICE PER YEAR. WHAT CODING
SYSTEM FOLLOWS THIS UPDATING SCHEDULE?
ICD-10-CM
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A MOTHER PRESENTS INS.. INFORMATION FOR HER SON'S OFFICE
VISIT. HE IS COVERED BY 2 POLICIES. THE MOM CARRIES1 POLICY
&DAD CARRIES THE OTHER. THE MOM'S BIRTHDAY IS NOV. 4, 1972.
AND THE DADS BIRTHDAY IS JAN. 4, 1973. WHAT INSURANCE PLAN
SHOULD THE EHR SPEC
THE DAD'S INSURANCE IS
PRIMARY AND MOM'S
INSURANCE IS SECONDARY
AN EHR SPECIALIST ENTERS A PT'S INSURANCE INFORMATION INTO
THE EHR SYSTEM. HOW LOG DOES IT TAKE TO POST TO THE PT'S
CHART?
AS SOON AS THE INFORMATION IS
ENTERED.
A PT IS ADMITTED WITH TONSILLITIS FOR WHICH A TONSILLECTOMY
WAS PERFORMED. DURING THE RECOVERY, THE PT FELL AND
FRACTURED THE RIGHT ULNA, REQUIRING REDUCTION OF THE
BONE. WHAT IS THE PRINCIPLE PROCEDURE LISTED?
TONSILLECTOMY
WHAT IS THE FIRST STEP WHEN PROCESSING A RECORD REQUEST IN
A MANUAL SYSTEM?
VALIDATE AUTHORIZATION FOR
RELEASE.
A PT PRESENTS TO A PROVIDERS OFFICE WITH STREP THROAT.
WHERE WOULD THE CLINICIAN DOCUMENT IN THE EHR ABOUT THE
ONSET OF STREP THROAT?
HISTORY OR PRESENT ILLNESS
WHAT IS INCLUDED IN AN IMPLANT REGISTRY?
MANUFACTURER
A PT'S MARITAL STATUS SHOULD BE DOCUMENTED WHERE?
SOCIAL HISTORY
WHERE IN THE EHR WILL THE EHR SPECIALIST FIND NECESSARY
DOCUMENTATION TO SUBSTANTIATE A SHORT TERM FOR A WOMAN
ON MATERNITY LEAVE?
DISCHARGE SUMMARY
WHAT IS INCLUDED ON A FACE SHEET?
ADVANCE DIRECTIVES
WHAT IS THE MOST IMPORTANT REASON A PROVIDER SHOULD
INCLUDE COMPREHENSIVE DOCUMENTATION IN THE PT RECORD?
TO DEMONSTRATE MEDICAL
NECESSITY THAT ENSURES
CORRECT PAYMENT TO THE
PROVIDER
AN EHR SPECIALIST WANTS TO DIFFERENTIATE THE HEALTH
INFORMATION RECORDED FOR PTS' WHO ARE PREGNANT. WHAT
SHOULD THE SPECIALIST DO?
DEVELOP A CLINICAL TEMPLATE
TO CAPTURE DATA SPECIFIC TO
THE DIAGNOSIS
FROM WHERE IN THE EHR IN THE PART OD SOAP NOTE WOULD AN
EHR SPECIALIST ABSTRACT A DIAGNOSIS?
ASSESSMENT
WHAT CAN BE INTEGRATED WITH AN EHR SYSTEM TO
AUTOMATICALLY GENERATE ICD AND CPT INFORMATION DIRECTLY
FROM CLINICAL DOCUMENTATION?
COMPUTER ASSISTED CODING
ACCORDING TO HIPAA WHAT IS A COVERED ENTITY?
CLEARINGHOUSE
ACCORDING TO HIPAA WHAT SITUATION IS A PT REQUIRED TO SIGN
AN AUTHORIZATION TO RELEASE PHI?
A SCHOOL REQUESTS A PEDIATRIC
PT'S PHYSICAL EXAM RESULTS FOR
SPORTS ELIGIBILITY
WHAT REFERS TO A PROVIDER'S LIABILITY FOR THE WRONGFUL ACTS
OF HIS EMPLOYEES?
RESPONDEAT SUPERIOR
WHAT SHOULD A PROVIDER'S OFFICE DOCUMENT TO DEMONSTRATE
IT IS HIPAA COMPLIANT
AUDIT TRAIL RESULTS
WHAT IS THE FUNCTION OF THE DRUG UTILIZATION REVIEW
FEATURE IN AN EHR SYSTEM?
TO FLAG POSSIBLE MEDICATION
INTERACTIONS
WHAT IS A BENEFIT OF INPATIENT HOSPITAL EHR SYSTEM?
PROVIDES ACCESS TO CURRENT PT
INFORMATION
WHAT IS THE MAIN REASON COMPUTERIZED PHYSICIAN ORDER
ENTRY (CPOE) SHOULD BE USED?
IT ELIMINATES ERRORS BY
TRANSCRIPTION OF
HANDWRITTEN OR VERBAL
ORDERS