question

the ability of electronic systems to share information in compatible formats.

answer

interoperability

question

the patients stated primary reason for seeking treatment.

answer

chief complaint

question

screen that contains the amount owed and other billing details.

answer

ledger

question

an EHR function that facilitates automated prescribing.

answer

CPOE-computerized physician order entry

question

a fixed sum of money usually paid at the time medical services are rendered.

answer

copayment

question

an electronic format that speeds the claims process for physicians and suppliers.

answer

HIPAA 5010

question

a register of business transactions for a single day.

answer

day sheet

question

data entry using structured data entry or voice recognition.

answer

electronic transcription

question

one of the eight core functions of an EHR designated by the IOM(institute of medicine).

answer

reporting and population health

question

an audit is performed by the office manager to investigate whether appropriate employees have viewed the contents of a high profile patients chart. t or f

answer

true

question

the medical record contains legal documents but is not itself a legal document. t or f

answer

false

question

the medicals assistants typical duties will be modified with the implementation of the EHR. t or f

answer

true

question

clinical decision support tools are effective only if the provider chooses to use them. T or f

answer

true

question

an EHR system can help the provider and medical staff plan and coordinate care for a patient with a chronic illness. t or f

answer

true

question

automated sentence building is a means of electronic transcription. t or f

answer

true

question

reduced productivity is to be expected for a period of time during the conversion of an EHR system. t or f

answer

true

question

communication among various treating healthcare providers, pharmacies, and allied healthcare workers will be limited until EHR interoperability has been achieved. t or f

answer

true

question

one of the core functions of the EHR includes the ability to assist providers with treatment protocol. t or f

answer

true

question

it is possible for individuals to penetrate EHR systems despite security systems. t or f

answer

true

question

EHR systems make it unnecessary for office staff to be familiar with medical terminology. t or f

answer

false

question

most EHR systems hold the ability to handle clinical and administrative functions without purchasing separate practice management software. t or f

answer

true

question

professional organizations offer continuing education for the core skills of their discipline and do not have any opportunities for learning about EHR. t or f

answer

false

question

what is a medical record?

answer

a complete physical collection of an individuals healthcare information.

question

in the us and other developed countries, healthcare providers are required by law to report new cases of HIV/AIDS and other communicable disease to the...

answer

CDC-centers for disease control and prevention

question

clinical information includes...

answer

medical list, allergies list, immunization records, laboratory records, pathology records, hospital records, history and physical assessment findings, risk assessment, preventive services, progress notes, vital signs and growth charts, imaging test results

question

administrative information is...

answer

information that the administrative staff uses from the medical record in order to perform front office activities such as maintaining appointments, storing patient contact information, and creating patient correspondence

question

administrative information includes...

answer

patient demographics, name of emergency contact, patient correspondence, referral and consultation letters, prior authorizations, insurance information and copies of insurance cards, HIPAA 5010 claims status, billing account ledgers, superbills, day sheets, appointment history, diagnoses and procedure codes

question

legal forms or documentation that can be part of a medical record.

answer

medical releases, general procedure forms, HIPAA forms, advanced directives, living wills, disclosure logs, healthcare power of attorney forms

question

an individual who is responsible for inputting patient information into the medical record is called a...

answer

documenter

question

who is the person/s to document information in the medical record?

answer

receptionist or other member of the front office, next it is, usually, the medical assistant and then the physician

question

who owns the medical record?

answer

the individual who created them such as, if a private practice created the medical record they own it, if a hospital created the record they own it and so on.

question

who owns the information within the medical record?

answer

the patient(the patient has the right to a copy but the original record never leaves the facility that owns it)

question

the eight core functions of an EHR system.

answer

1. health information and data 2. results management 3. order management 4. decision support 5. electronic communication and connectivity 6. patient support 7. administrative processes 8. reporting and population health

question

the eight core functions of the EHR system was created by...

answer

IOM (institute of medicine)

question

an electronic patient record created and maintained by a medical practice or hospital.

answer

EMR-electronic medical record

question

an interconnected aggregate of all the patients health records, pulled from multiple providers and healthcare facilities.

answer

EHR-electronic health record

question

some of the capabilities of the commercial EHR...

answer

provider review of incoming lab data, reports storage of office forms electronic signature insertion fax and messaging functions to transmit prescriptions reminders that patient is do for a screening summary and print functions and more...

question

clinical decision support tools allow providers to do the following.

answer

1. ensure that the patients care compiles with established screening recommendations 2.plan treatment in accordance with evidence-treatment guidelines 3. generate patient data reports and summaries 4. complete documentation templates specific to the patients diagnosis 5. perform data base searches to identify patients who meet specific criteria 6. share best practices regarding treatment and diagnosis of disease 7. reduce the amount of testing 8. improve clinical outcomes and reduce misdiagnoses 9. reduce cost for unnecessary testing 10. improve patient safety

question

allows efficient handling of all front office administrative procedures, including entering patient demographics, tracking billing and insurance information, scheduling appointments, and processing payments for patient visits.

answer

PMS-practice management software

question

what is socioeconomic data information?

answer

age, sex, marital status, education, occupation, and perhaps religious preference

question

the most common way of appointment scheduling is a ....

answer

fixed schedule-when a patient is asked to appear in the office at a specific date and time

question

typical fixed appointments range from...

answer

10 to 30 minutes for acutely ill established patients to one hour for new patient visits

question

accounting procedures performed by practice management software include...

answer

management and creation of statements, generation of day sheets, and completion of HIPAA 5010 claim format

question

HIPAA 5010

answer

a standard electronic format that speeds claims processing for physicians and suppliers

question

advantages of EHR's

answer

improved quality and continuity of care increased efficiency improved documentation easier accessibility at the point of care better security reduced expenses improved job satisfaction improved patient satisfaction

question

disadvantages of EHR's

answer

lack of interoperability cost employee resistance regimentation security gaps

question

the basic skills needed to help you use an EHR effectively.

answer

1. a working knowledge of medical terminology and anatomy and physiology 2. basic typing and computer skills 3. organizational skills 4. interpersonal skills

question

cross-training

answer

is being able to perform more than one duty or skill across various task areas

question

the EHR aids in billing and coding tasks in the following ways.

answer

submission of superbills creation of billing statements assignment of procedural and diagnostic codes linking of procedural and diagnostic codes auditing organizing office finance generating prior authorization forms monitoring submission and follow up of claims

question

account ledger

answer

an accounting billing document that lists services provided, copayments made by the patient, reimbursement received from the patients insurance company and outstanding amount owed

question

audit

answer

a review of employee activity with in the EHR system, including an examination of which files were accessed or modified, when and why

question

CCHIT -certification commission for healthcare information technology

answer

a recognized certification body for EHR systems and their networks.

question

CDS-clinical decision support

answer

a set of patient-centered tools embedded within EHR software that can be used to improve patient safety, ensure that care conforms to protocol for specific conditions, reduce duplicate or unnecessary care and its associated cost

question

CPOE-computerized provider order entry

answer

an EHR function that allows the physician to order medications and tests. reduces prescribing errors, delays and duplication, and simplify inventory and billing processes

question

continuity of care

answer

a key aspect of quality that encompasses planning and coordination of care, communication among members of the healthcare team, and accessibility and transportability of information

question

day sheet

answer

a register for daily business transactions; also called a day journal

question

electronic transcription

answer

data entry into the EHR using handwriting recognition, voice recognition, electronic sentence building, scanning and other means

question

encounter

answer

a documented interaction or visit between patient and healthcare provider

question

interoperability

answer

the ability to separate EHR systems to share information in compatible formats

question

PIF-patient information form

answer

a form used to gather information about the patient, including basic demographic information, medical insurance data, and emergency contact

question

PMS-practice management software

answer

software used in the medical office to accomplish administrative tasks

question

structured data entry

answer

documentation using controlled vocabulary via preloaded data, drop down boxes, radio buttons and sentence builders

question

third-party payer

answer

a party other than the patient, spouse, parent or guardian who is responsible for paying all or part of the patients medical costs, typically the insurance company

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