question

President Bush recommended the use of Health Information Technology H I T. And set a goal for all Americans to be using Electronic Health Records EHR by what year?

answer

2004

question

HIPAA act of 1996

answer

was designed to protect a patients private health information, ensure healthcare coverage for workers who lost or changed their jobs, and help uncover fraud or abuse in healthcare.

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The Institute of Medicine

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Suggests EHR have 8 core elements. Health Information & Data Elements, Results Management, Order Management, Decision Support, Electronic communications & Connectivity, Patient Support, Administrative Process,Reporting & Population Management

question

Electronic Medical Records \"EMR\"

answer

Computerized records of one physician's encounter with a patient over time.

question

Electronic Health Record \"EHR\"

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a computerized lifelong health care record for an individual that incorporates data from providers who treat the individual.

question

Personal Health Record \"PHR\"

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Maintained and owned by the patient. Information sheet that contain the individual's medical history, including diagnoses, symptoms, and medications

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Acute Care

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Most often refers to a Hospital, treats patients with urgent problems.

question

Ambulatory Care

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Another term for outpatient care

question

Advantages of Electronic Health Records

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* Safety * Quality of Care * Efficiency * Cost Reduction

question

Total Conversion

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may be costly; allows all patient data to be converted at once while office still sees patients

question

Incremental Conversion

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gradual change to EHR, lower cost, smoother transition and less impact on office, however paper is still used and not all patient data available

question

Hybrid Conversion

answer

uses combination of paper and electronic forms of data

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Clinical Vocabularies

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Set of common definitions for medical terms they ease communication by decreasing ambiguity

question

SNOMED-CT \"Systematized Nomenclature of Medicine Clinical Terms\"

answer

Clinical Vocabulary disigned to encompass all terms used in medicine

question

LOINC \"logical observation identifier names and codes\"

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Terms and codes used for electronic exchange of lab results and clinical observations.

question

UMLS \"Unified Medical Language System.\"

answer

Thesaurus database of medical terms.

question

ICD-9 & ICD-10

answer

international classification of diseases developed by the World Health Orgnanization \"W H O\"

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CPT

answer

current procedural terminology developed and maintained by the AMA

question

Code Range for Evaluation & Management \"E&M\"

answer

99201-99499

question

Code Range for Anestesia

answer

00100-01999

question

Code Range for Surgery

answer

10021-69990

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Code Range for Pathology & Lab

answer

80047-89356

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Code Range for Medicine

answer

90281-99607

question

HCPCS

answer

Healthcare common procedural coding system.

question

HCPCS Level II

answer

Contains codes for products, supplies and certain services not included in the CPT manual. These codes are maintained by the Centers for Medicare and Medicaid Services. CMS

question

Standard: Health Level Seven \"HL7\" 2.3+

answer

Scheduling, medical record and image management, patient administration, observation reporting, financial management, public health notification, and patient care.

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National Council for Prescription Drug Programs \"NCPDP\" SCRIPT

answer

Retail pharmacy transactions

question

Institute of Electrical and Electronics Engineers, Inc. \"IEEE\"

answer

Device/device transactions

question

Digital Imaging and Communicatons in Medicine \"DICOM\"

answer

Image information to workstations

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HL7 version 2.4+

answer

Demographics

question

Systematized Nonmenclature of Medicine Clinical Terms \"SNOMED CT\"

answer

Lab Result contents

question

HL& Version 2.x+

answer

Units of measure

question

CVX

answer

vaccines administered

question

MVX

answer

manufacturers of vaccines

question

CDC

answer

Centers for Disease Control and Prevention

question

NIP

answer

National Immunization Program

question

Active Ingredient

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FDA established names & \"Unique Ingredient Identifier Codes\" UNII

question

Manufactured Dosage

answer

FDA/CDER data standards manual

question

Drug Product

answer

FDA National Drug Codes \"NDC\"

question

Medication Package

answer

FDA Standards manual

question

Label Section Headers

answer

LOINC Clinical Structured Product Labeling \"SPL\"

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HL7 \"Health Level Seven International\"

answer

Is a standard for exchanging information between medical applications. This standard defines a format for the transmission of health-related information.

question

Drug Classifications

answer

Department of Veteran Affairs National Drug File Reference Terminology \"NDF-RT\"

question

Clinical Drug

answer

National Library of Medicine's Rx Norm

question

Verbal Communication

answer

Oral communication; Speech. The process of sending and receiving messages with words, including writing and sign language.

question

Nonverbal Communication

answer

Use of eye contact , Body Language, facial expression, or symbolic expressions to communicate a message

question

Respect

answer

courteous regard for people's feelings

question

Step 1 of patient flow

answer

appointment scheduling Information collecting

question

Step 2 of patient flow

answer

Patient Check-in payment collection

question

Step 3 of patient flow

answer

Rooming Measurements Vitals Patient Examination and documentation

question

Step 4 of patient flow

answer

Patient Checkout

question

Step 5 of patient flow

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Coding and Billing Review test results

question

Vital signs

answer

measurements of physiological functioning, specifically body temperature, pulse, respirations, and blood pressure; may include pain level and pulse oximetry

question

Chief Complaint

answer

main reason for the visit to the medical office.

question

Progress Notes

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Record of the continuing progress and treatment of a patient.

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Past Medical History \"PMH\"

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A listing of any illnesses the patient may have had in the past; includes treatments and procedures performed.

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Family History

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review of medical events in the patients family

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Social History

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a detailing of the patient's lifestyle and personal habits

question

Allergies

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A list of the patients allergies as well as their reactions to each one

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Medication List

answer

Information regarding the dosage and frequency of the patients medication

question

History of present illness \"HPI\"

answer

a description of the course of the present illness,including how and when the problem began, up to the present time

question

Review of Systems \"ROS\"

answer

systematic head to toe review \"questions about\" all major body systems

question

Diagnosis and Assessment

answer

The physicians conclusion regarding the cause of the patients problem

question

Clinical Tools

answer

EHR'S allow the ability to access research, detail national treatment,eaiser to manage patients w/chronic deseases, allow doctors to Order tests, medications, Send prescriptions to pharmacy, checks medication contradictions & errors.

question

E-Prescribing

answer

Transmission of a prescription via electronic means. EHR programs will send alerts for potential prescription problems.

question

The Primary Benefits of Hospital EHR

answer

* Unlimited access to patients information *Decreased waiting time for medication delivery as well as test results *Increased efficiency and accuracy in overall patient care

question

Computerized Physician Order Entry \"CPOE\"

answer

is an application used by physicians and other health care providers to enter patient care information

question

The five rights of eMars

answer

1. The right patient 2. The right medication 3. The right dose 4. The right time 5. The right route \"oral or intravenous\"

question

Adverse drug effects \"ADE\"

answer

Side effects or complications from medications

question

Benefits of the Personal Health Record \"PHR\"

answer

The elimination of errors made by patients filling out forms, records can be accessed from any location. Ensures the safety of health records located in healthcare facilities in the event of a natural disaster.

question

Computer Based -Stand Alone

answer

*transferred to a portable memory device to be accessed from a different location *access to their PHR using a software program that has been downloaded or installed onto their computer

question

Internet Based-tethered

answer

accesses through outside organization such as insurance company limited editing capability. ownership of helath care record is maintained by the organization that provides access to the user.

question

Internet Based-Untethered

answer

Individuals are granted access to their personal health record through a web based application. Upon the creation of a user name and password the user is able to create and update information as needed.

question

Internet Based-networked and interoperable

answer

Networked personal health record allows transfer of personal health record to providers such as insurance companies and pharmacies. Continually updated does not ensure privacy and security

question

HIPAA Title I

answer

Insurance reform--The purpose is to provide continuous insurance coverage for workers and their insured dependents when they change or lose their job.

question

HIPAA Title II

answer

Provides rights for the transfer of electronic health care data. Adminstration and Simplification Standards \"Title II\" put privacy and security mechanisms in place to ensure personal health info is kept confidential.

question

Health Plan

answer

individual or group plan that provides or pays for medical care

question

Providers

answer

anyone who provides medically related services that can be reimbursed. A provider may be a physician, dentist, clinic, hospital, pharmacy, lab

question

Clearinghouses

answer

Companies that process health information and execute electronic transactions

question

Designated Record Set \"DRS\"

answer

any item, collection, or grouping of information that includes protected health information and is maintained by a covered entity

question

Electronic Protected Health Information \"ePHI\"

answer

Protected health information that is created, received, maintained or transmitted in electronic form

question

Notice of Privacy Practices \"NPP\"

answer

document that described practices regarding the use and disclosure of protected health information

question

Protected Health Information \"PHI\"

answer

Individually identifiable health information that is transmitted or maintained by electronic media.

question

Treatment, Payment and Operations \"TPO\"

answer

Conditions under which protected health information can be released without consent from the patient

question

The following is considered \"PHI\"

answer

*Name * Address *Names of relitives and employees *Social Security Number *Phone & fax numbers *Email addresses *Health Plan ID number *Account number ETC.....

question

Rights of Individuals

answer

Access copy of PHI, request amendment of record, request restrictions on uses and disclosures of PHI, and file a complaint about a violation with the Office of Civil Rights

question

National Council for Prescription Drug Program

answer

A standardized system used to transfer prescription information

question

Deep

answer

Away from the surface

question

Proximal

answer

close to the origin of the body part or the point of attachment of a limb to the body trunk

question

Distal

answer

farther from the origin of a body part or the point of attachment of a limb to the body trunk

question

Inferior

answer

below another structure

question

Superior

answer

above another structure

question

Medial

answer

Toward the midline of the body.

question

Lateral

answer

pertaining to the side

question

Supine

answer

lying on the back

question

Prone

answer

lying on the belly

question

2014

answer

In what year must everyone be using the EHR system

question

Level II HCPCS

answer

product supplies services not included in CPT manual

question

Order Sets

answer

pre-defined groupings of standard orders for a condition, disease or procedure

question

The center for Medicare and Medicaid Services \"CMS\"

answer

Maintain the HCPCS codes

question

Decision support tools

answer

makes the last clinical information available to provide at the point-of-care

question

Medical Records

answer

An important business document , a medical record is used to support treatment decisions, document services provided & could be used in a court of law for evidence purposes,

question

Plan & Treatment

answer

The physicians recommended plan of action to cure or manage patients condition

EHR Electronic Health Record

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