EHR – Ch #2
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Memorial Hospital is in the process of researching a new facility-wide electronic health record system. The ___________________ would be responsible for assessing the budgeting process, funding, and for monitoring the monetary aspects of the project.
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chief financial officer. Part of the responsibility of the chief financial officer is to develop budgets and monitor spending.
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Roberta has an associate degree and holds RMA certification. She mainly performs administrative duties such as appointment scheduling, registering patients, and maintenance of health records in a large physician's practice. She occasionally performs clinical duties as well, as needed. Roberta is a/an:
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medical assistant. A registered medical assistant performs the typical administrative duties of a regular MA, with the added ability to handle periodic clinical duties.
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In a hospital setting, the management and much of the staff of the department responsible for entering, maintaining, and retrieving data from health records, are often certified through and members of which professional organization?
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American Health Information Management Association (AHIMA). The AHIMA certifies health professionals who work with health data and information.
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Which of the following requires completion of a competency exam, but does not result in certification?
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Practice Workflow & Information Management Redesign Specialist. While there is no certification for it, health professionals must pass a competency exam to be known as a Practice Workflow & Information Management Redesign Specialist.
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The health information manager and the ___________________ work closely to ensure a fully operational, secure electronic health record that meets the needs of all users within the facility?
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Information Technology Manager/Officer. The health information management and information technology departments are closely related. The HIM managers ensure the information collected satisfies legal, accreditation, and patient care-related data. The IT managers ensure the security, interoperability, and performance of electronic systems.
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Robert Fitzsimmons is an administrator with the local hospital. His responsibilities include the maintenance and security of all of the automated systems that affect individual departments as well as the electronic health record. Mr. Fitzsimmons is a/an:
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health systems administrator Though a hospital's health information department is responsible for many EHR-related issues, it is the health systems administrator who is responsible for all of the technological aspects of automated systems within the hospital.
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The staff of the ___________________ will need to enter, maintain, and retrieve data from electronic health records within a hospital setting.
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health information department A hospital's health information department is responsible for EHR-related duties.
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Until recent years, Registered Health Information Technicians, Registered Health Information Administrators, and Certified Health Data Analysts typically worked in which type of facility?
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hospitals Though the credentialed individuals may work in any healthcare setting, they are most commonly employed by acute care hospitals. (Note - this information is found in table 2.1.)
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Which of the following is not a professional organization related to the fields of health information, medical assisting, or allied health?
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American Hospital Association The American Hospital Association does not certify individual professions.
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Philip is a medical assistant who has been working for a medical practice with two physicians and one physician's assistant for three years. He recently applied for a supervisory position within the office, but was overlooked for the position. He is anxious to take his knowledge and experience to the next level, but never took a certifying exam, and to this point has not taken advantage of continuing education opportunities. What is the best strategy for Philip to strengthen his chances of promotion in the future?
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begin studying for one of the medical assisting certifying exam and schedule a date to take it Certification and continuing education show that the individual has incentive, background knowledge and current knowledge in his/her field.
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A ______________________ professional would most likely hold one of the following positions: cancer registrar, privacy officer, software analyst, compliance officer.
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Registered Health Information Administrator (RHIA) Health Information professionals have the education and background necessary to hold any of the positions listed.
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In a physician's practice, ________________ may be the title of the person who is responsible for the overall administrative management of the practice.
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Office Administrator An office administrator is tasked with keeping the entire office running smoothly.
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An x-ray of the ankle was performed on Daniel Way on December 16. Dr. Eberly interpreted the x-ray and dictated his impression, which then became part of the hospital's electronic health record. This impression is ________________________ data.
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unstructured The report is unstructured because it contains a narrative of the physician's findings.
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Dr. Henderson wrote a progress note in the emergency room note of Lisa Ford. This is an example of _________________ data.
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unstructured The report is unstructured because it contains a narrative of the physician's findings.
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The progress note of Amy Shaw states that she is a 51-year-old female who has a history of lower back pain following a fall off a ladder in 2007. She has been taking ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs to miss work. Based on her history and the results of the physician's physical exam, his treatment plan is naproxen sodium daily and an order for physical therapy to include TENS treatments with follow-up visit scheduled in four weeks. This is an example of a patient's health _______________________.
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information The individual pieces of data (age, medical history) give the physician the information he needs to determine a treatment plan.
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The date of birth on a patient's record is ___________________ data.
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structured Because the date of birth is entered in a pre-defined manner, for instance MMDDYYYY and can be used to run reports or to extract data, the date of birth is structured data.
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A zip code would be an example of _______________ data.
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structured A zip code equates to a particular municipality; because it is in coded format, it is structured data.
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A record that contains a person's health history, allergies, current complaints, past medical and surgical history, and a listing of current medications, but is not considered a legal health record is a/an:
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personal health record Patients may compile their health related information using summary medical reports; because it is incomplete and unofficial, it cannot be considered a legal document.
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Typically, paper health records are maintained how?
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filed in folders in numeric or alphabetic order Paper records are filed in the facility where they originated, alphabetically by patient's last name or numerically by health record number.
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Entering data into a computer system is also known as ________________ data.
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capturing Saving information into computer software is known as data capture.
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When collecting data on a computer or retrieving data from a computer, the screen becomes the replacement for ______________.
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paper Rather than writing or reading from a piece of paper, or typing the physician's dictation into a transcribed paper report, data is found on the computer screen.
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The capturing of data about a patient begins at what point?
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when the patient calls for an appointment or arrives at the hospital for care At the time a patient calls the office (or arrives at the hospital) identifying information is collected, which starts the record for that patient.
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What is the name of the screen that is open?
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facesheet In the center of the Page, near the top, the word Facesheet appears.
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The patient has a heart rate of 68 and a blood pressure of 110/65. These are known as:
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vital signs The data related to vital signs is found under the Vital Signs bar.
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The ____________ allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information.
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Electronic Health Record (EHR) Having all medical information stored in an electronic record makes sharing that information quick, easy, and accurate.
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Of the following, which is not a core function of the EHR as defined by the Institute of Medicine?
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filing of insurance claims Though filing of electronic claims is part of administrative processes and reporting, it is not specifically one of the eight functions.
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Information that identifies the patient in any way is known as _________________.
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protected health information Protected health information is any information, such as name, address, phone number, or medical information, that identifies the patient.
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The ________________________ is published by the federal government and includes all actions taken by any government entity on a given date.
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Federal Register The Federal Register is published daily by the U.S. government and details all actions taken that day by the government.
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The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the _______________________.
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American Recovery and Reinvestment Act HITECH standards fall under the American Recovery and Reinvestment Act.
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\"A set of standards, services, and policies that enable the secure exchange of health information over the Internet\" is known as:
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National Health Information Network The National Health Information Network provides guidance on securely exchanging information over the Internet.
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In order to send and accept diagnosis codes using ICD-10-CM, which version of the HIPAA Code Set rule was effective as of January 1, 2012?
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version 5010 There is no version 3010 or 6010; 5010 was the revision to version 4010 of the code set rule.
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This entity was founded in 2004 to certify electronic health records.
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Certification Commission for Health Information Technology CCHIT was founded in 2004 to certify EHRs.
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A unique identifier that is required on claim forms and identifies the care provider or group practice submitting the claim is the:
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National Provider Identifier number The social security number of the care provider is not used, nor is his/her license number. Care providers do not have policy numbers, except for their own, personal insurance plan that covers themselves and their spouse or family.
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In a physician's office, the equivalent of a hospital's master patient index is a/an:
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patient list In a physician's practice, the list of all patients ever seen in the office is most commonly referred to as the patient list.
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In a hospital setting, when the patient presents for care he/she is:
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registered Since patients most often do not actually schedule appointments to be seen in a hospital, they are registered rather than scheduled for an appointment.
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The hospital equivalent to practice management software used in the physician's practice is known as:
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Registration, Admission, Discharge, Transfer System In the hospital setting, patients need to be registered or admitted (for an inpatient stay), discharged when they have vacated the bed, and transferred if they are moved from one bed to another.
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John Smith was admitted to Memorial Hospital on June 6 and died while in the hospital, on June 10. The action taken on June 10 was a/an:
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discharge Though Mr. Smith died, this was still a discharge since he no longer occupied a hospital bed.
