EHR HS220 – Flashcards

Previous patient visits or previous patient encounters.

To compare the change of certain test components over a period of time. Results with numerical values can be graphed.

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.

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 died.

Disease management Graphic analysis Trending Preventative screening * Interactive alerts

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.

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

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.

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

Electronic lab orders and results Vital Signs ECG Digital spirometers Ultrasound equipment Holter monitors In-?house LIS systems

Curved lines representing what percentage of the reference population the individual would equal or exceed at a given size for age.

Transactions and Code Sets Uniform Identifiers Privacy Security *

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.

No.*

Healthcare providers,health insurance plans, clearinghouses. *

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 records.

Ophthalmology and dermatology were examples provided in the textbook. (Allow for other reasonable answers, such as cardiovascular, obstetrics, orthopedic,and general surgeons.)

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.

Message integrity, nonrepudiation, and user authentication.

History, Examination, Medical Decision Making.

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.

EPHI*

PKI

BMI

HCPCS*

MMR*

OCR*

HPI*

VPN*

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 supply.*

The New Encounter window.

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.

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

History of Present Illness

Diagnosis or Assessment

Head, Ears, Eyes, Nose and Throat

Upper Respiratory Infection

Prefix

October 2013.

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)