GG MOA 160 EHR chapter 1

the ability of electronic systems to share information in compatible formats.
the patients stated primary reason for seeking treatment.
chief complaint
screen that contains the amount owed and other billing details.
an EHR function that facilitates automated prescribing.
CPOE-computerized physician order entry
a fixed sum of money usually paid at the time medical services are rendered.
an electronic format that speeds the claims process for physicians and suppliers.
HIPAA 5010
a register of business transactions for a single day.
day sheet
data entry using structured data entry or voice recognition.
electronic transcription
one of the eight core functions of an EHR designated by the IOM(institute of medicine).
reporting and population health
an audit is performed by the office manager to investigate whether appropriate employees have viewed the contents of a high profile patients chart. t or f
the medical record contains legal documents but is not itself a legal document. t or f
the medicals assistants typical duties will be modified with the implementation of the EHR. t or f
clinical decision support tools are effective only if the provider chooses to use them. T or f
an EHR system can help the provider and medical staff plan and coordinate care for a patient with a chronic illness. t or f
automated sentence building is a means of electronic transcription. t or f
reduced productivity is to be expected for a period of time during the conversion of an EHR system. t or f
communication among various treating healthcare providers, pharmacies, and allied healthcare workers will be limited until EHR interoperability has been achieved. t or f
one of the core functions of the EHR includes the ability to assist providers with treatment protocol. t or f
it is possible for individuals to penetrate EHR systems despite security systems. t or f
EHR systems make it unnecessary for office staff to be familiar with medical terminology. t or f
most EHR systems hold the ability to handle clinical and administrative functions without purchasing separate practice management software. t or f
professional organizations offer continuing education for the core skills of their discipline and do not have any opportunities for learning about EHR. t or f
what is a medical record?
a complete physical collection of an individuals healthcare information.
in the us and other developed countries, healthcare providers are required by law to report new cases of HIV/AIDS and other communicable disease to the…
CDC-centers for disease control and prevention
clinical information includes…
medical list, allergies list, immunization records, laboratory records, pathology records, hospital records, history and physical assessment findings, risk assessment, preventive services, progress notes, vital signs and growth charts, imaging test results
administrative information is…
information that the administrative staff uses from the medical record in order to perform front office activities such as maintaining appointments, storing patient contact information, and creating patient correspondence
administrative information includes…
patient demographics, name of emergency contact, patient correspondence, referral and consultation letters, prior authorizations, insurance information and copies of insurance cards, HIPAA 5010 claims status, billing account ledgers, superbills, day sheets, appointment history, diagnoses and procedure codes
legal forms or documentation that can be part of a medical record.
medical releases, general procedure forms, HIPAA forms, advanced directives, living wills, disclosure logs, healthcare power of attorney forms
an individual who is responsible for inputting patient information into the medical record is called a…
who is the person/s to document information in the medical record?
receptionist or other member of the front office, next it is, usually, the medical assistant and then the physician
who owns the medical record?
the individual who created them such as, if a private practice created the medical record they own it, if a hospital created the record they own it and so on.
who owns the information within the medical record?
the patient(the patient has the right to a copy but the original record never leaves the facility that owns it)
the eight core functions of an EHR system.
1. health information and data
2. results management
3. order management
4. decision support
5. electronic communication and connectivity
6. patient support
7. administrative processes
8. reporting and population health
the eight core functions of the EHR system was created by…
IOM (institute of medicine)
an electronic patient record created and maintained by a medical practice or hospital.
EMR-electronic medical record
an interconnected aggregate of all the patients health records, pulled from multiple providers and healthcare facilities.
EHR-electronic health record
some of the capabilities of the commercial EHR…
provider review of incoming lab data, reports
storage of office forms
electronic signature insertion
fax and messaging functions to transmit prescriptions
reminders that patient is do for a screening
summary and print functions
and more…
clinical decision support tools allow providers to do the following.
1. ensure that the patients care compiles with established screening recommendations
2.plan treatment in accordance with evidence-treatment guidelines
3. generate patient data reports and summaries
4. complete documentation templates specific to the patients diagnosis
5. perform data base searches to identify patients who meet specific criteria
6. share best practices regarding treatment and diagnosis of disease
7. reduce the amount of testing
8. improve clinical outcomes and reduce misdiagnoses
9. reduce cost for unnecessary testing
10. improve patient safety
allows efficient handling of all front office administrative procedures, including entering patient demographics, tracking billing and insurance information, scheduling appointments, and processing payments for patient visits.
PMS-practice management software
what is socioeconomic data information?
age, sex, marital status, education, occupation, and perhaps religious preference
the most common way of appointment scheduling is a ….
fixed schedule-when a patient is asked to appear in the office at a specific date and time
typical fixed appointments range from…
10 to 30 minutes for acutely ill established patients to one hour for new patient visits
accounting procedures performed by practice management software include…
management and creation of statements, generation of day sheets, and completion of HIPAA 5010 claim format
HIPAA 5010
a standard electronic format that speeds claims processing for physicians and suppliers
advantages of EHR’s
improved quality and continuity of care
increased efficiency
improved documentation
easier accessibility at the point of care
better security
reduced expenses
improved job satisfaction
improved patient satisfaction
disadvantages of EHR’s
lack of interoperability
employee resistance
security gaps
the basic skills needed to help you use an EHR effectively.
1. a working knowledge of medical terminology and anatomy and physiology
2. basic typing and computer skills
3. organizational skills
4. interpersonal skills
is being able to perform more than one duty or skill across various task areas
the EHR aids in billing and coding tasks in the following ways.
submission of superbills
creation of billing statements
assignment of procedural and diagnostic codes
linking of procedural and diagnostic codes
organizing office finance
generating prior authorization forms
monitoring submission and follow up of claims
account ledger
an accounting billing document that lists services provided, copayments made by the patient, reimbursement received from the patients insurance company and outstanding amount owed
a review of employee activity with in the EHR system, including an examination of which files were accessed or modified, when and why
CCHIT -certification commission for healthcare information technology
a recognized certification body for EHR systems and their networks.
CDS-clinical decision support
a set of patient-centered tools embedded within EHR software that can be used to improve patient safety, ensure that care conforms to protocol for specific conditions, reduce duplicate or unnecessary care and its associated cost
CPOE-computerized provider order entry
an EHR function that allows the physician to order medications and tests. reduces prescribing errors, delays and duplication, and simplify inventory and billing processes
continuity of care
a key aspect of quality that encompasses planning and coordination of care, communication among members of the healthcare team, and accessibility and transportability of information
day sheet
a register for daily business transactions; also called a day journal
electronic transcription
data entry into the EHR using handwriting recognition, voice recognition, electronic sentence building, scanning and other means
a documented interaction or visit between patient and healthcare provider
the ability to separate EHR systems to share information in compatible formats
PIF-patient information form
a form used to gather information about the patient, including basic demographic information, medical insurance data, and emergency contact
PMS-practice management software
software used in the medical office to accomplish administrative tasks
structured data entry
documentation using controlled vocabulary via preloaded data, drop down boxes, radio buttons and sentence builders
third-party payer
a party other than the patient, spouse, parent or guardian who is responsible for paying all or part of the patients medical costs, typically the insurance company

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