question

Medicin

answer

A medical nomenclature and knowledge base developed by Medicomp Systems Inc.

question

ICD-9-CM

answer

Code to classify mortality and morbidity. International Classification of Disease, 9th revision, Clinical Modification

question

Explain the difference between an EHR nomenclature and a billing code set.

answer

EHR codes details and Billing Code Sets is patient details

question

Which screen do you use to set the reason for visit?

answer

On the new encounter form

question

How do you enter vital signs?

answer

Click the forms button in the tool bar then the vitals option

question

How do you load a list?

answer

highlight the list wanted and press the load list button

question

ROS:

answer

Review of Systems

question

Hx:

answer

History

question

HPI:

answer

History of Present Illness

question

Dx:

answer

Diagnosis

question

HEENT:

answer

Head. Eyes. Ears. Nose.Throat

question

URI:

answer

Upper Respiratory Infection

question

Describe how to record a test that was performed.

answer

Select the test then go to prefix and select performed from the drop down list.

question

What Entry Details field is used with a finding to indicate a"possible" diagnosis?

answer

select diagnosis then go to prefix and select possible

question

What month and year is the United States scheduled to begin using ICD-10?

answer

October 2013

question

Describe the closed loof of medication administration.

answer

Electronic prescription CPOE then sent to pharmacy

question

Compare the advantages of codified EHR data over scanned document data.

answer

EHR is a larger variety of body systems and functions that can go from general to specific.

question

Name at least 3 things that are checked by a DUR alert system.

answer

Underdosing, Overdosing and Allergic Reactions

question

List Size:

answer

shrinks or expands the tree list based on diagnosis

question

Rx:

answer

adds prescription drugs to plan, orders meds

question

Search:

answer

opens a window to find items more easily

question

Negs:

answer

marks no for symptoms patient does not have

question

ROS:

answer

Review of systems looks at parts affected by the chief complaint

question

Prompt:

answer

adds more detail to the search

question

Order:

answer

orders the test related to the encounter form

question

Where does the data that appears in the patient management tab come from?

answer

the existing encounter form from previous visits

question

Why would clinicians use trending of lab results and what type of results can be graphed?

answer

medication, current test results and physical changes over time; Numerical values

question

Describe the benefits of having patients entering their own symptoms and history.

answer

the patient knows their history and can decribe their own symptoms better than someone else; primary source of past medical social history; can review history to be better prepared for appointment; primary source of the outcome of symptom awareness

question

Why are child immunizations important?

answer

Immunizations slows down or stops disease outbreaks

question

List 3 ways that codified data in the EHR can be used to manage and prevent disease.

answer

disease management, graphic analysis, interactive alerts

question

Describe a problem list and provide at least 2 reasons why clinicians use a problem list.

answer

a problem list is an up-to-date list of diagnosis and conditions that affect a particular patients care. easy to see active problems for a patient, view the history of the problems

question

Describe how to create a flow sheet from a form.

answer

while on the form tab with a form loaded, click on the button labeled "FS Form"

question

What does it mean to cite a finding and how would you do it from a flow sheet?

answer

citing from previous exam notes means to bring a finding into the encounter usually as a follow-up from 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

question

How does an E-visit differ from provider-to-patient emails?

answer

E-visit is more secure

question

What are "evidence-based" guidelines?

answer

"evidence-based" guidelines are ways to analyze scientific evidence from current research and studies to determine the effectiveness of preventative services.

question

Name at least 3 external sources of data for populating the EHR?

answer

electronic lab orders and results, vital signs, ECG

question

What is a growth chart percentile?

answer

curved lines representing what % of the reference population the individual would equal or exceed at a given size or age

question

List 4 components of the HIPAA Administrative Simplification Subsection.

answer

transactions and code sets, uniform identifiers, privacy and security

question

Compare the difference between HIPAA consent and HIPAA authorization.

answer

authorization requires the patient's permission to disclose PHI; signed consent is optional

question

Does a provider need the patient's consent to share PHI with an authorized government agency?

answer

No

question

Name the covered entities under HIPAA.

answer

healthcare providers, health insurance plans, and clearing houses

question

Name some of the advantages of PHR.

answer

available wherever the patient is treated, PHR is secure and private and is owned and managed by the patient. Patients control who can access their records.

question

Give an example of a specialty that might use annotated drawings in an encounter note.

answer

Opthalmology and Dermatology

question

How is the Internet changing healthcare?

answer

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.

question

List 3 criteria of an electronic signature.

answer

message integrity, non-repudiation, and user authentication

question

Name the key components of an E&M code.

answer

history, examination, medical decision making

question

Where are "bullets" used in E&M calculation.

answer

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

question

EPHI

answer

information protected by the Security Rule

question

PKI

answer

Electronic Signature standard

question

BMI

answer

calculation for height/weight ratio

question

HCPCS

answer

Procedure Code Set

question

MMR

answer

three vaccines

question

OCR

answer

enforces HIPAA Privacy Rule

question

HPI

answer

element of a patient exam

question

VPN

answer

method of internet security

EHR Final test – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards