question

What does EHR stand for?

answer

Electronic Health Records

question

What is the definition of an EHR?

answer

The portions of a patient's medical records that are stored in a computer system as well as the functional benefits derived from having an electronic health record

question

Explain the benefits of EHR over paper charts.

answer

Simultaneously accessible at multiple locations by multiple providers; searchable by computer; data are more likely to be standard medical terms

question

What are some additional benefits realized from having codified EHR data?

answer

Health maintenance, trend analysis, alerts, decision support

question

Describe what points of the workflow are different between offices using a paper and an electronic chart system

answer

Some EHR offices allow scheduling online; paper charts have to be pulled the night before while electronic systems can automatically verify patient's insurance eligibility; paper systems have the patient update his/her history on paper form while the electronic system has the patient answer questions on a computer in the lobby; the paper system has to hand record everything while the electronic system has the information electronically transferred from instruments into the chart; paper systems rely on memory while EHR completes the chart with the patient present or shortly thereafter

question

Name at least 3 forces driving the change to EHR

answer

Medical specialization (patients no longer have one doctor); Increasingly mobile society (patients relocate and change doctors often); Internet (patients are researching their conditions and demanding access to their own records); health safety (deaths as a result of a medical error that could have been prevented)

question

What are the four goals of the Strategic Framework created by the Office of the National Coordinator for Health Information Technology?

answer

1. Inform clinical practice 2. Interconnect clinicians 3. Personalize care 4. Improve population health 5. Patient-focused healthcare

question

Describe at least 3 differences between inpatient and outpatient EHR systems.

answer

Outpatient: Single chart per patient that is added to with each visit; quantity of data is relatively low by comparison, central element in chart is the physician's exam note Inpatient: New chart each time a patient is admitted, larger quantity of data (nurses notes are added numerous times throughout the day), main focus is the physician's orders and the nurse's notes indicating patient's response

question

Explain why documenting at the point of care improves patient healthcare.

answer

Ensures a more accurate record, provides the most benefits from the system, allows the note to be completed before the patient ever leaves the office, clinician can sign note immediately, patient leaves with a copy of their record (a step that stimulates compliance), delivery process is improved because referrals can be accomplished with full information available at time that referral is needed

question

What is the HITECH Act?

answer

The Health Information Technology for Economic and Clinical Health Act provides CMS incentives for providers to use a certified EHR

question

What is the name of an organization that certifies EHR systems?

answer

Certification Commissions for Healthcare Information Technology (CCHIT)

question

List the 3 styles of the physician-patient relationships described by Wenner and Bachman

answer

1. The doctor is paternalistic, telling the patient what to do 2. The doctor gives the patient information and the patient decides what to do 3. Patients and doctors share information to determine the best plan for given conditions

question

List the 8 core functions that an EHR should be capable of performing

answer

1. Health information and data 2. Result management 3. Order management 4. Decision support 5. Electronic communication and connectivity 6. Patient support 7. Administrative processes and reporting 8. Reporting and population health

question

List the 3 criteria of an EHR defined by CPRI

answer

1. Capture data at the point of care 2. Integrate data from multiple sources 3. Provide decision support

question

What are the 4 defined sections in a SOAP note?

answer

Subjective Objective Assessment Plan

question

What are 3 benefits of electronic results identified by the IOM report?

answer

1. Electronic results for better interpretation 2. Quickers recognition, treatment of medical problems 3. Reduces redundant testing 4. Improves care coordination among multiple providers

question

Name 3 forms of EHR data

answer

Digital images, text data, discrete data

question

Name at least 2 medical code sets considered national standards

answer

MEDCIN, NANDA, CCC, ICNP

question

What is a nomenclature?

answer

A system (or list) of names used in a field of science, typically created by a recognized group or authority. In an EHR, the term is used for organized lists of medical phrases and codified to help standardize the way clinicians record information. EHR nomenclatures are also called clinical vocabularies or clinical terminologies.

question

In an EHR, what is meant by the term \"finding\"?

answer

Findings are codified observations that are medically meaningful to clinicians

question

Describe the different between an EHR nomenclature and a billing code set.

answer

The level of details represented by codes. EHR nomenclatures have codes to represent not only procedures and diseases, but also symptoms, observations, history, medications, and a myriad of other details. EHR nomenclatures contain cross references to other codes sets, billing codes sets do not.

question

What is one advantage of codified data over imaged data?

answer

When EHR data is coded, it can be used for trending, alerts, health maintenance, and decision support; it can be accurately identified and electronically compared by computer. Document image data required a human being to read the information.

question

What is trend analysis?

answer

Graphs or comparison of data from different dates, tests, or events.

question

What is decision support?

answer

Providing reference information just when the clinician needs it; examples include prescription drugs, drug formalities, generic or therapeutically equivalents to brand-name drugs.

question

What are alerts?

answer

A message or reminder that is automatically generated from the data.

question

What is health maintenance?

answer

Reminders to make patient aware when it is time for a preventative procedure or a check-up, a flu shot, or other immunization.

question

List at least 2 ways codified data in the EHR can be used to manage and prevent disease.

answer

Disease management, graphic analysis, trending, interactive alerts

question

Name at least 2 benefits of having patients entering their own symptoms and history into the computer.

answer

Only patient has information about what symptoms are present at onset of illness; only patient has information about what outcome of medical treatment of those symptoms was; patient is source of past medical, family, and social history.

question

Name a type of decision support.

answer

Defined protocols, drug formularies, medical dosing, results of case studies

question

Name some advantages of electronic prescriptions

answer

Physician issues and records prescription in chart in one step; prescription is then sent electronically from physician's computer system to pharmacy, saving time for patient and elimination need for doctor's staff to call in prescription; reduces errors caused by handwritten prescriptions

question

What is HL7?

answer

National communication standard for transferring health data between disparate systems; stands for Health Level Seven

question

Which menu did you use to select the patient?

answer

Select

question

Which menu did you used to start a new encounter?

answer

Select

question

Where did you set the label \"10 minute visit,\" which appeared in the title of the window?

answer

Encounter Reason field

question

What does the abbreviation Sx represent?

answer

Symptom

question

What does the abbreviation Hx stand for?

answer

History

question

What does the abbreviation Px stand for?

answer

Physical Exam

question

What does the abbreviation Tx stand for?

answer

Tests (performed)

question

What does the abbreviation Dx stand for?

answer

Assessment (diagnosis is also permitted)

question

What does the abbreviation Rx mean?

answer

Plan or Therapy (also ordered tests)

question

What was the patient's chief complaint?

answer

Headaches for more than 5 days

question

Where in the Entry Details section did you record the frequency and duration of her headaches?

answer

Episode (widow or button)

question

What was the clinical assessment (her diagnosis)?

answer

Vasoconstrictor withdrawal headache from caffeine

question

How did you invoke the Vital Signs window?

answer

Click the button labeled Forms on the Toolbar and then click the form name

question

How do you remove a finding?

answer

Locate and click on underlined portion of the finding in the right pane and then click on the delete button located below the right pane

question

How did you invoke the Chief Complaint window?

answer

The button labeled Chief on the Toolbar

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