Integrated Electronic Health Records Chapters 7 & 8
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which is used to code procedures in an office, is an example of a
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code set
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The law which strengthened HIPAA privacy and security regulations was:
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Health Information Technology for Economic and Clinical Health Act (HITECH)
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HIPAA defines a patient's name, social security number, employer, or medical record/account numbers that tie information to a particular person as:
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protected health information
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Keeping health information to oneself is known as protecting:
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confidentiality
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E-mails or faxes that are sent and arrive at the wrong location constitute a privacy _____________.
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breach
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Blocking access to a facility's computer systems by unauthorized users is accomplished through use of _______________.
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a firewall
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Of the following, which password is most secure?
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Record**58
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Nancy Jackson is the office manager of a medical practice. Each month she reviews a report that shows which staff members viewed, edited, or deleted data on a random selection of patient's records, and whether or not the access or the actions taken were justified. Nancy is performing which function?
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auditing
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CPT, which is used to code procedures in an office, is an example of a/an _____________.
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code set
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In 2004, the ______________, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology organized the Certification Commission for Health Information Technology.
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American Health Information Management Association
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Each person who has the ability to access a computer software system is set up within the software and assigned a/an __________________, which is typically based on their name.
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user ID
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James Philips has asked that certain personnel within the office be prohibited from seeing his health information. This record will be flagged as?
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restricted access
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When correcting written documentation in a paper record, it is necessary to:
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cross out the incorrect information with one line, enter the correct information, date and initial the correction
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How is a correction made to an electronic health record?
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The incorrect entry is corrected and the original entry is hidden from view, but is still retrievable
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An employee at Memorial Medical Practice released the diagnosis of a patient to the patient's spouse without an authorization. This is known as a/an _________________________.
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breach of confidentiality
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Lisa Haver is a patient of Dr. Randolph's. You have just opened today's mail and opened a letter from Ms. Haver's attorney because she is involved in a lawsuit regarding an auto accident. What will you do?
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look for a signed authorization in the envelope which authorizes the office to release Lisa Haver's records to the attorney
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You are the office manager of Greensburg Medical Center. You have received a letter from one of your patients, Ida Healthway, asking to know the names of all employees and care providers who have accessed her EHR within the last year, since she believes someone has been spreading information about her in the community. You will provide Ms. Healthway with this information, which is known as:
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accounting of information disclosures
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Some states have a Health Information __________________, funded through the ONC, which allows the sharing of health information for continuity of care purposes.
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Exchange
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A staff member who monitors existing and new regulations and is the \"go-to\" person should an incident occur is known as the _____________________.
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compliance officer
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In order for the healthcare facility to know what to do in case of a situation that interrupts access to the EHR, a written ____________________ should be in place.
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disaster recovery plan
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Which of the following may result in the need to deploy the disaster recovery plan?
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A computer hacker has gained access to the database and corrupt files have been found
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\"Which of the following is not included in the Notice of Privacy Practices? A. how a patient's health information may be used B. the name of the individual to whom a record was released C. that the patient may request correction or amendment to their health record D. entities to whom a patient's information may be released
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the name of the individual to whom a record was released
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Healthcare providers, clearinghouses, and insurance plans are able to access protected health information (PHI) when needed under HIPAA. These healthcare providers are known as what under HIPAA?
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covered entities
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The right to be left alone, or in healthcare, to undergo care without others infringing on one's personal space is known as what?
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privacy
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The fact that a patient is either admitted to or is undergoing treatment in a facility, and his or her location within the facility is known as what kind of information?
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Directory information
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To help guard against unauthorized individuals accessing a practice's computer system, a unique access code that is known only to the user is used. What is this unique access code called?
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a password
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Facilities typically have policies prohibiting the downloading of music, pictures, and the like in order to prevent attacks from viruses or ______ that might be carried on downloaded items.
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malware
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What is the process whereby electronic transmission of any health information sent in such a way that it cannot be read without a special code that reads it?
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encryption
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In addition to the American Health Information Management Association, an independent, name another non-profit organization that promotes the effective use of health information technology.
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The Healthcare Information and Management Systems Society
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What is the name of the private, non-profit organization that certifies EHR software?
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CCHIT Certification Commission for Health Information Technology
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Data that is timely, consistent, secure, and correct is said to have data __________________.
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integrity
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Records were released to a life insurance company without authorization, and the release was not required by law. This is known as a/an _______________.
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breach of confidentiality
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Dr. Patterson has referred his patient, James Holt, to a dermatologist. James' records were sent electronically to the dermatologist's office. The release of records was done to ensure _______________ of care.
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continuity
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Upon request, Greensburg Medical Center provides patients with a report detailing the disclosures made to external agencies as well as all accesses to a patient's EHR internally. What is this process of providing a listing of the information released and to whom it was released known as?
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accounting of disclosures
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Ongoing communication about a particular topic, for instance satisfaction with a medical office, may be posted on a __________, a social media format where an author provides periodic commentary on various issues.
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blog
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Some offices conduct periodic internal ___________________ on every staff member and care provider for the purpose of determining compliance with data use policies.
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audits
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In order to deter unauthorized access to documentation and patient information, data may be ___________________.
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encrypted
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A suspicious e-mail was received at Greenway Medical Center and included an attachment. the IT consultant informed the office manager that the system was infected by a computer virus because the system was unprotected from outside access. How could the office have avoided such a situation?
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Installing a firewall would have prevented this attack.
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Greensburg Medical Center uses an electronic health record. Anna Oliver, a patient there, has written a letter to the health information manager requesting an accounting of disclosures from her health record during the period of January 1, 2011 through and including June 30, 2011. Is the health information manager able to do this? Explain.
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HIPAA and HITECH rules specify that patients may be given a full accounting of all disclosures (internal and external) of his or her health information, who received or accessed the information, and what was accessed, the date(s) on which it occurred, and the reason the access was made.
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Explain why the Certification Commission for Health Information Technology (CCHIT) was formed.
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The purpose of forming CCHIT was to have a non-government, non-profit organization whose function would be to certify electronic health information software.
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Many offices use an internal, secure environment to communicate important information to their employees. This is known as a/an?
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Intranet
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A hard copy document such as an insurance card may be converted to digital format for inclusion in a patient's health record. The process of converting the document from paper format to digital format is known as _________________.
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scanning
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Preformatted documents built into the practice management and electronic health record software are known as:
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templates
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In the field \"Primary Language\", English appears in the field. This is known as a ___________ value.
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default
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Datasets that provide structure and are the building blocks for parts of the health record are known as ____________ files.
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master
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Dr. Handley prefers to see the Facesheet of her patients in a particular order. Dr. Adams prefers to see his in another order. The software used in their office allows each provider to view screens in a different way. This is known as:
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customization
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A functionality of an EHR or other software that allows the user to assign an electronic \"to-do\" list to themselves or other employees is known as the:
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task list
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Jeannie Clark has requested to be put on a payment plan for her outstanding balance. She came to the office today and while registering her, the healthcare professional saw a dialogue box which alerted her not to collect a late fee. This reminder is known as a ______________.
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flag
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The quality of a digital image is known as the:
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resolution
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Greenway Medical Center uses a priority ranking system for their internal e-mail. The fact that the holiday luncheon will be held on December 6, 2011 would be a __________ priority email.
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low
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Instant access to information is available through a public series of networks. What is this network commonly called?
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Internet
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What is the name of the technology used to scan images and then convert them to a format that is readable by the computer?
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optical character recognition
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Dr. Henderson's office has been installing an EHR system in their office over the past few months. On January 2, 2014, they will begin using the new system for all patients seen on that date and going forward. Using the system for the first time is referred to as what?
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\"Going live\"
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Master files are __________________ that provide structure and are the building blocks for parts of a provider's chart notes.
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datasets
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What step(s) should be taken to ensure a scanned image is properly filed within a patient's health record?
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Scanned images must first be verified to ensure they are made a part of the correct patient's record as well as the correct encounter for that patient.
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A new staff member in your office has a question about scanning. How would you explain the process to her?
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Lay the document on the screen, follow the prompts, and merge the digital copy into the proper patient's health record.
