Electronic Medical Record Flashcards, test questions and answers
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Electronic Medical Record
Health Computing
Medicare And Medicaid Services
Nursing
Intro to Occupational Therapy Chapter 13 – Flashcards 50 terms
50 terms
Preview
Intro to Occupational Therapy Chapter 13 – Flashcards
question
What is patient documentation part of?
answer
Direct patient care.
question
What is Productivity?
answer
The standard of efficiency set by each practice setting.
question
What does it mean if productivity is 70%
answer
The billable patient therapy for the workday is also 70%
question
Is 90% productivity an unrealistic standard for an OTA?
answer
It is unrealistic but some companies expect it.
question
What could interfere with good time management with regards to shared supplies and work space in the OT environment?
answer
Needed supplies being left in a disorganized manner. Missing supplies and needed supplies being left in a disorganized manner.
question
How do unorganized supplies interfere with the OT process?
answer
It infringes on good time management. Bottom line, it wastes time.
question
What does the phrase, "many hands make light work" have to do with orderliness in the supply cabinet etc.
answer
Everyone on every shift should keep supplies in an orderly fashion. For shared equipment, each person is responsible for pitching in, reporting broken items, notifying others when supplies are low and cleaning up after themselves.
question
An example of irresponsibility concerning tools etc.
answer
One shift using all the clean linens, gowns and towels and leaving no supplies for the other discipline to use in their learning lab that follows later in the day.
question
What is the shared home living space in the OTA program at PV consist of?
answer
Kitchen, bathroom, laundry room, living room, office and bedroom. Assistive technology lab and splinting lab.
question
What does it mean to use correct Body mechanics?
answer
Using proper form when using the body to prevent injury. Ex: bending at the knees to lift with the legs.
question
What is involved in CPR?
answer
The ability to perform basic first aid and take vital signs, (pulse, respiration, blood pressure).
question
What do most institutions require if one works to reduce your risk of contracting diseases?
answer
Medical examination, chest X ray, TB trest and HBV series (3 shots taken over time)
question
In the state of Kansas OT practitioners must have how many continuing education units every two years and how do you prove it?
answer
40 CE units every two years proven by documentation
question
Does the state of Ks give OT practitioners give CE credit for supervising Level 2 fieldwork students?
answer
Yes
question
Clinical/fieldwork educators (OTs or OTAs) must have what before taking a level 2 student?
answer
At least one year of experience.
question
An OT practitioner may take a level 1 Fieldwork student if they have less that one year experience?
answer
True
question
According to AOTA what is the practitioner's professional responsibility ? What is one way to do so?
answer
To give back to the profession...one way is by becoming a clinical educator.
question
Why are clinical educators (level 1 and 2 fieldwork supervisors) needed?
answer
Without them students would not be able to graduate from accredited OT and OTA programs.
question
After an employee attends a conference, how may they be of benefit to their employer?
answer
Upon return from the workshop/conference the employee will do a department in-service so the other practitioners can benefit from the updated information gathered at the session.
question
What does HOTFA stand for?
answer
Heartland Occupational Therapy Fieldwork Alliance
question
What does membership in AOTA & KOTA do for the OT profession?
answer
It ensures the profession is represented and that we all have jobs that pay well.
question
What is another way OT's help the profession?
answer
Through Public relations and MARKETING OF THE OT PROFESSION
question
What is an example of EVIDENCE BASED PRACTICE: Researching information that supports clinical interactions.
answer
Knowing that medication from the doctor has research backing up the value of taking it for the intended purpose.
question
Does evidence based research apply to OT interventions?
answer
OT's research and back up why we do and what we do. It is every OT's responsibility!
question
During the OT evaluation what happens?
answer
Data is collected about the client An initial note/treatment plan is written.
question
Who writes the initial note/treatment plan?
answer
The OTR with input from the OTA
question
What is included in the initial note?
answer
Strengths, problems, long (LTG) and short term goals (STG) along with methods to be used and frequency of treatment.
question
How does the practitioner determine what methods will be used?
answer
By using critical thinking skills to individualize the OT intervention program.
question
What is treatment based on?
answer
Evidence or research that supports the practitioner's actions.
question
What is another name for evidence based practice?
answer
Best practice
question
Should an OT program should be repetitious?
answer
No. It should be novel and interesting to the patient.
question
What is meant by the big broad picture?
answer
The long term goal.
question
What does the long term goal emphasize?
answer
Promoting functional independence in the pt.'s environment. It is a statement of what the Pt will look like at discharge, about 3-4 weeks.
question
What are short term objectives/goals?
answer
STB's are smaller steps toward the long term goal. What will be accomplished in 1 -2 weeks.
question
What are identified in STG's and who establishes them?
answer
STG's are desired outcomes/solutions that the practioner and the CLIENT together establish.
question
Going to Hawaii by August is a type of what goal?
answer
Long term goal?
question
What would a short term goal be?
answer
Deposit $150 per month for 10 months to go to Hawaii.
question
What should be in goal criteria?
answer
It must be M.A. R. R. U measurable, achievable, reasonable, reachable ....annnnnd. WRITTEN in a format so that it is evident it is accomplished.
question
Grading treatment:
answer
Setting goals for and with client to see improvement in functional independence.
question
As treatment progresses the practitioner will?
answer
Increase the demand on the client by changing the conditions to achieve higher level of success.
question
STG example
answer
seated at sink, shave 3 x's per week.
question
upgrade example
answer
standing at sink client shaves 3 x's per week.
question
Graded down
answer
intervention strategy is too difficult for client and must be modified to make it more successful.
question
DOCUMENTATION:
answer
*write down any/all contact with client
question
Non standardized forms
answer
documentation forms that are not 'across the board" consistent.
question
S.....OAP
answer
subjective, what the patient verbalizes
question
S...O.......AP
answer
O...objective, observable data, what was done/accomplished in therapy, and the test results.
question
SO A P
answer
A Assessment, practitioner's opinion
question
SOA P
answer
P Plan, future plan of action
question
Bottom line of documentation
answer
If it isn't written down it looks like it wasn't done.
Clinical Decision Support
Electronic Health Record
Electronic Medical Record
Health Computing
Patient And Family Education
Root Cause Analysis
Chapter 7: E-Medicine in Respiratory Care – Flashcards 59 terms
59 terms
Preview
Chapter 7: E-Medicine in Respiratory Care – Flashcards
question
what is the definition of E-Medicine?
answer
refers to the use of computerized or digital technology to enhance efficiency and effectiveness of health care and more specifically patient care
question
what are examples of E-Medicine?
answer
digital applications related to electronic health records, disease management, etc
question
what are electronic health records(EHR)?
answer
the sum of all electronic medical records produced by a patient during the different encounters with various health care entities throughout a lifetime
question
what are electronic medical records(EMR)?
answer
computerized records produced every time a patient uses health services; owned by the hospital or health care organization
question
what are examples of nonclinical information that is also saved electronically?
answer
patient demographics, health insurance, history and physical exam, progress notes, labs/tests, and vitals
question
why does it help that physician orders are also computerized?
answer
it saves time and reduces transcription errors due to handwriting clarity issues and also helps facilitate patient care and reduce medical errors
question
what are the issues in health care organizations when it comes to software packages?
answer
using separate software packages for individual functions
question
what is the Health Information Technology for Economic and Clinical Health Act(HITECH Act)?
answer
its part of a national strategy for building a national health information infrastructure
question
why is it good to use a single comprehensive software package to address issues?
answer
to provide integral functionality to enhance both efficiency and effectiveness, as well as comply with HITECH Act
question
what are some applications of electronics in diagnostics?
answer
hemoglobin monitoring, blood gas and point-of-care testing, medial imaging applications, and pulmonary function testing
question
what is PACS?
answer
an application that allows for imaging storage, portability, communication, and clinical integration of all imaging modalities with the EHR
question
what are the 2 applications of electronics in acute care settings?
answer
mechanical ventilators and therapist-driven protocols
question
what do mechanical ventilators have the potential to do?
answer
to improve the quality and consistency of ventilator charting; also improve completeness, accuracy, consistency, and efficiency
question
what do therapist-driven protocols do?
answer
evidence-based protocols can improve health outcomes; automated protocols can assist with spontaneous breathing trials
question
what is an example of an automated breathing trial?
answer
ventilator weaning
question
what are the applications of technology in non-acute care settings and chronic diseases?
answer
to develop protocols to address main reasons for readmissions to emphasize patient and family education and follow-up
question
what are the 2 chronic diseases?
answer
asthma and COPD
question
what does technology do to help monitor asthma?
answer
use monitored patient data to tailor the adjustment to the plan of care
question
what does technology do to help monitor COPD?
answer
E-medicine applications facilitate education, self-management, and timely feedback from health care providers
question
what are the 3 types of treatments for tobacco use and dependence?
answer
phone-based applications, internet-based treatment programs, and automated contacts via e-mail or text messages
question
what are health informatics?
answer
combines advances in computer science and technology to improve clinical care, manage the health of populations, and accelerate research
question
what is business intelligence(BI)?
answer
set of tools that permit capture, storage, and transformation of data into useful and actionable information
question
what are key performance indicators(KPI)?
answer
indicators of quality and efficiency that are selected based on reporting or operational requirements
question
what is the purpose of telemedicine?
answer
support health care at a geographically different location from the patient to increase access to specialty care
question
when coupled with electronic health record, clinical decision is particularly useful in: a. disease management b. influenze care c. resp. therapy d. post-trauma care
answer
a. disease management
question
in what automated response. care protocol has shown that use of a handheld computer helped shorten the patient's stay in the ICU? a. ventilator initiation b. ventilator weaning c. high-flow oxygen (O2) therapy d. airway care
answer
b. ventilator weaning
question
the process by which the underlying primary, secondary, and other notable causes of a medical error are indentified is referred to? a. continuous quality improvement b. a root-cause analysis c. value-based purchasing d. web analytic
answer
b. a root-cause analysis
question
which of the following are ways health care workers and facilities conform to HIPPA regulations concerning securing patient confidentiality within electronic medical records? 1. refraining from sharing passwords 2. accessing electronic patient information only on a need- to-know basis 3. utilizing thumbprint protected security 4. allowing close family members to view patient health information from a hospital computer
answer
1,2, and 3
question
what are the 3 basic missions of academic medicine?
answer
to heal, to teach, and to discover
question
what entity is responsible for approving experimental procedures prior to collecting data? a. AARC b. IRB c. NBRC d. NIH
answer
b. IRB
question
what search engine looks for scholarly publications in a wide variety of fields and includes peer-reviewed manuscripts, abstracts, theses, and books from academic publishers, professional societies, and university libraries? a. Medline.org b. Google Scholar c. Minimed.org d. Cochrane.org
answer
b. Google Scholar
question
what is the name of the database often purchased and used by hospitals and university libraries to provide key research information on a large variety of medical topics? a. SPAN b. OVID c. CINUP d. MITO
answer
b. OVID
question
which of the following describes a database that is a structured collection of facts? a. synthesized databases b. portal databases c. electronic journal databases d. bibliographic databases
answer
d. bibliographic databases
question
True or false: the membrane that covers the lungs is called the visceral pleura
answer
true
question
what is a faster than normal, very rapid respiratory rate called?
answer
tachypnea
question
what does dyspnea mean?
answer
labored or difficult breathing
question
what does apnea mean?
answer
temporary cessation of breathing
question
what does bradypnea mean?
answer
abnormally slow breathing
question
the condition used to define when the chest wall moves paradoxically with respiration as a result of multiple fractures of the ribs is called what?
answer
flail chest
question
what does hemothorax mean?
answer
blood in the thoracic cavity
question
what does pleural effusion mean?
answer
accumulation of fluid in the pleural space, which compresses the underlying position of the lung; resulting in dyspnea
question
what is silicosis?
answer
a lung disorder caused by inhalation of silica dust, resulting in the formation of small nodules
question
what is apnea also known as?
answer
asphyxia
question
what is heart failure from pulmonary disease called?
answer
cor pulmonale
question
what is congestive heart failure(CHF)?
answer
defective blood-pumping system, marked by breathlessness and abnormal retention of sodium and water
question
what is myocardial infarction?
answer
gross necrosis of the myocardium, caused by decreased blood supply to the area
question
what is a pneumothorax?
answer
a collection of gas or air in the pleural cavity, resulting from a perforation through the chest wall or the visceral pleura
question
what is pleurisy?
answer
inflammation of the pleura
question
what is pertussis?
answer
acute upper respiratory infectious disease caused by bacterium, bordetella pertussis, commonly called whooping cough
question
what is Cheyne-Stokes?
answer
a condition where the patient breathes deeply a short time and then breathes slightly or stops altogether with the cycle repeating itself
question
what is SIDS?
answer
sudden infant death syndrome; cause unknown; associated with failure of synapse of nerves to activate diaphragm
question
what is Kussmaul breathing?
answer
gasping, labored breathing, also called air hunger
question
what is arrhythmia?
answer
irregular heartbeat or a variation from the normal heart beat
question
what is an aortogram?
answer
an invasive diagnostic test using a catheter to inject dye into the aorta
question
the is the bundle of His?
answer
cardiac muscle fibers connecting the atria with the ventricles of the heart
question
what is the pulmonary semilunar valve?
answer
located between the right ventricle and pulmonary artery
question
what is the vena cava?
answer
largest vein going all through the body
question
what is the epicardium?
answer
the visceral pericardium
question
true or false: cardiac arrest is the cessation of heart function
answer
true
Acute Care Setting
Electronic Medical Record
Physical Therapist Assistant
Physical Therapy
Quantity And Quality
Surgical Technology
1.4 Manual Therapy – Flashcards 72 terms
72 terms
Preview
1.4 Manual Therapy – Flashcards
question
T/F: manual therapy can be included in the objective part of an exam and used in assessment and treatment of a patient as well
answer
true
question
Define Manual Therapy (3 purposes)
answer
skilled hand movements to mobilize soft tissue and joints for the purpose of: -pain modulation -inc in ROM -dec in soft tissue inflammation
question
Define mobilization/manipulation (general):
answer
manual therapy techniques comprised of skilled passive movements to joint that are applied at varying speed and amplitudes
question
Define mobilization (specific):
answer
a passive movement technique performed by an operator in a manner that is at all times *within the ability of the patient to prevent the movement*
question
Define manipulation (specific):
answer
a passive movement technique performed at the limit of the available passive range at a *speed that is beyond patient control*
question
Define thrust manipulation:
answer
*high velocity, low amplitude* therapeutic movements applied within or at the end range of motion
question
REVIEW OF TERMS (read)
answer
velocity = speed amplitude = distance thrust = force
question
What are examples of mobilization techniques?
answer
Passive physiological movement (PPM) Passive accessory movement (PAM)/joint play
question
Osteokinematics is associated more with ________ (PAM/PPM) whereas arthrokinematics is more associated with _______ (PAM/PPM)
answer
PPM - osteo PAM - arthro
question
Describe PPM:
answer
-movement of bones -movement you see -voluntary
question
Describe PAM:
answer
-movement of joint -movement you feel -involuntary
question
Manual therapy techniques involve what joint kinematic motions?
answer
glide and distraction (roll and spin are accessory movements and are considered part of joint play)
question
What are some characteristics that create variability in joint play?
answer
-person to person -joint to joint -w/in same joint depending on ROM available (close and loose packed) -trauma, muscle tension, pain, laxity, inflammation etc.
question
Limitation in motion can be due to either osteokinematics or athrokinematics. What is the #1 reason why each would limit motion?
answer
osteo: *muscle strength* main cause of limited motion (may also be joint capsule or ligaments) arhtro: *ligaments* main cause of limited motion (may also be joint congruency or integrity of cartilage/menisci)
question
Summary of difference b/w chiropractic and PT manipulation techniques (read):
answer
-PT philosophy is different (why we perform it) -chiropractors perform more often, PTs perform only when needed -techniques are different (PT use min force, chiro use max force)
question
Why do PTs perform manipulation when chiropractors are more skilled in this?
answer
it is within our scope of practice, because we are educated on it and are knowledgeable about when it is/isn't useful it would be unethical if we determined it beneficial for a patient and didn't use it
question
T/F: every state in the US allows for PTs to use manipulation as part of our treatment plan
answer
*False* (WA, AR, WV do not allow performance of manipulation by PTs) *it is important to know your state practice act for legal purposes*
question
Is there evidence to support the use of manual therapy in PT practice?
answer
"Manual therapy is beneficial for certain people (only) when performed with exercises"
question
What are 3 possible mechanisms which explain the effectiveness of manual therapy?
answer
-neurophysiological/chemical -mechanical -psychological/placebo (don't underestimate)
question
What is the neurophysiological/chemical explanation for the effectiveness of manual therapy? (4)
answer
-descending pain inhibitory system -endogenous opioid release -gate control theory -change in reflex excitability
question
What is the mechanical explanation for the effectiveness of manual therapy?
answer
-free up entrapped/torn meniscoid -mechanical disruption to intra-articular adhesions -stretching of joint capsule (mechanical effect difficult to prove)
question
T/F: the placebo effect plays a large part in the effectiveness of manual therapy
answer
true "take advantage of the placebo effect" -could be beneficial in finding a window to dec pain and perform exercise
question
What are categories of absolute contraindications of manual therapy?
answer
-malignancy -neurological -vascular -bone diseases -inflammatory conditions -infections -acute symptomatic disc herniation -*undiagnosed pain*
question
What are the neurological contraindications for manual therapy?
answer
-cauda equina syndrome -spinal cord compression -motor nerve root compression
question
What are the vascular (& skin) contraindications for manual therapy?
answer
-vertebral artery insufficiency -hemophilia -hx of anticoagulant therapy -acute infection -open wound
question
What are the bone pathologies that are listed as contraindications for manual therapy?
answer
-fracture -spondylolisthesis (could be precaution) -foraminal encroachment
question
What inflammatory conditions are a contraindication for manual therapy?
answer
-RA (could be precaution) -active inflammation -ankylosing spondylitis
question
What are relative contraindications for manual therapy? (12) (use clinical judgement to decide)
answer
-RA -osteoporosis -spondylolisthesis -gross degenerative changes -hypermobility/instability -pregnancy -previous malignancy -acute trauma -protective spasm -psychological pain -severe nerve root pain -steroid or anticoagulant
question
What are contraindications/precautions for peripheral joint manipulation?
answer
-recent trauma -ligament injury -immediate post op -empty end-feel or muscle spasm -acute inflammation
question
What are indications for manual therapy?
answer
-mild or moderate neuromusculoskeletal pain -joint hypomobility -a non-irritable, mild/moderate irritable condition -remodeling stage of recovery (subacute) -acute spinal pain w/o neurological symptoms
question
What are the 2 grading scales for distractions? What type of motion is involved with each?
answer
Kalternborn - static hold Maitland - oscillatory motion
question
What grading system is used for accessory glides?
answer
maitland (oscillatory)
question
accessory glides can be performed parallel or _________ to joint surfaces
answer
perpindicular
question
In the Kaltenborn distraction grading system, what does a grade 1 distraction accomplish? (3) Which patient population is this beneficial for?
answer
-unloads and decompresses joint surfaces -neutralizes pressure in joint *w/o actual surface separation* -produces pain relief by reducing compressive forces Grade 1 = loosen -used with *acute conditions* for pain relief
question
In the Kaltenborn distraction grading system, what does a grade 2 distraction accomplish? (4)
answer
-*separation* of joint surfaces -eliminates play w/in joint capsule -used initially to determine joint sensitivity -pain relief Grade 2 = tighten/take up slack
question
In the Kaltenborn distraction grading system, what does a grade 3 distraction accomplish? (3) What patient population can this be beneficial for?
answer
-joint capsule and ligament stretch -increases mobility in hypomobile joint -can be used w/ joint mobilization for hypomobile joints Grade 3 = stretch -beneficial for patients with chronic conditions (assessing flexibility of joint capsules and ligaments)
question
The maitland grading system is graded based on _________ of movement and ________ application at a specific point in range
answer
amplitude of movement force application
question
How many grades are there in the Maitland grading system?
answer
5 1-4 = oscillatory 5 = non-oscillatory
question
T/F: the Maitland grades are progressive as you move from 1-5 and are in continuum
answer
false
question
T/F: the Maitland grades will fall in the same place of a patient's available ROM whether they have a pathology or not
answer
false, the grades will change where they fall in the patient's available ROM, (shorter ROM based on the abnormal restriction)
question
In the Maitland grading system, where does grade 1 fall within the available ROM? Large or small amplitude?
answer
first 25% small amplitude (in resistance free range)
question
In the Maitland grading system, where does grade 2 fall within the available ROM? Large or small amplitude?
answer
middle 50% large amplitide (in resistance free range)
question
In the Maitland grading system, what are grades 1 and 2 used for? What type of effect do they have?
answer
used for pain control have a neurophysiological effect
question
In the Maitland grading system, where does grade 3 fall within the available ROM? Large or small amplitude?
answer
last 50% large amplitude (up to or into resistance)
question
In the Maitland grading system, where does grade 4 fall within the available ROM? Large or small amplitude?
answer
last 25% small amplitude (into resistance)
question
In the Maitland grading system, what are grades 3 and 4 used for? What effect do they have?
answer
-used for treatment of joint restriction and pain -have neurophysiological and mechanical effects -selectively activates muscle and joint mechanoreceptors
question
Describe a grade 5 Maitland manipulation
answer
-high velocity -low amplitude -thrust movement to the limit of available or mid-range
question
What is a grade 5 Maitland manipulation used for? What effects does it have?
answer
-used for pain control (spinal) and restoration of joint mobility -decreases pain, restores joint motion, breaks adhesions and remove loose bodies -has neurophysiological, mechanical, and placebo effects
question
What might help determine if you need to use manipulation over mobilization technique?
answer
when progress plateaus or symptoms do not improve with the use of mobilization
question
For grades 1-5 for the Maitland system, which are used for assessment or treatment?
answer
Grades 1-4: -assessment and treatment Grade 5: -treatment only
question
T/F: Manipulation techniques are more effective than mobilization techniques
answer
False, there is nothing saying that one is more effective than the other necessarily, but depending on the patient's characteristics one may be more/less indicated than another
question
What information can be gathered as part of the subjective exam that may help determine if a patient will benefit from manual therapy?
answer
*age* -bone maturity level, bone density, pain sensation etc. *psychological status* *special questions* -contraindications *SINS* -has manual therapy worked/not worked in the past? Did they have a good experience? *History*
question
What information can be gathered in the objective exam that may help determine if a patient will benefit from manual therapy?
answer
*AROM* *PROM* -overpressure and end feel *CPR* -present/absent? *joint integrity/mobility* -accessory glides (and joint distraction?) *# of joints involved* *neurological findings*
question
When assessing joint glides as part of the objective exam, what are 3 possible results you could have, and what does each indicate?
answer
*un-restricted* -motion limitation due to contractile tissues *excessive* -ligament or severe degeneration of joint surfaces *restricted* -joint restriction or limited by connective tissues
question
Which type of accessory joint glide provides an indication for the use of manual therapy as part of a patient's POC?
answer
restricted accessory glide
question
When assessing joint distraction during an objective exam, what are the possible results you could have and what does each indicate?
answer
*Pain w/ traction* -connective tissue tear (decrease pain with compression) *Restricted motion w/ traction* -connective tissue restriction *Relief of pain w/ traction* -joint surface problem (pain inc w/ compression = articular surface pathology)
question
T/F: joint mobility is easy to assess
answer
false difficult to assess, graded in milimeters by "end feel" -poor intra/intertester reliability -MUST compare to un-involved side
question
T/F: as part of your objective exam in determining if you should use MT, you should assess grades 1-4 of Maitland
answer
true
question
What should you include in documentation of your assessment of Maitland grades 1-4?
answer
Quantity and quality of motion -normal -limited or stiff -hyper/hypomobile Reproduction of symptoms -inc or dec pain -muscle spasms present/absent
question
What should be considered in the assessment of a patient to determine if manual therapy may be used as part of the treatment plan?
answer
-knowledge of joint surfaces and biomechanics -irritability of symptoms -working hypothesis -focus of treatment (pain and/or resistance)
question
Which mobilization technique(s) should you utilize in a patient's treatment if pain control is your main priority? *know this*
answer
Maitland oscillation *grade 1 and 2* (1-2 bouts of 20-30 secs) Kaltenborn distraction *grade 1 and 2* (1-2 bouts of 10-20 sec static hold) *Grade 5* manipulation (spinal pain)
question
With pain control as your focus in treatment, you should chose a least painful technique with _____ (high/low) speed, and a _________ (shorter/longer) treatment
answer
low speed shorter treatment
question
Which mobilization technique(s) should you utilize in a patient's treatment if resistance is your main focus?
answer
Maitland oscillation *grade 3 and 4* (3-5 bouts of 45-60 sec) Kaltenborn distraction *grade 3* (3-5 bouts, 30-60 sec) *Grade 5* manipulation
question
With resistance as your focus in treatment, you may start mobilization with more _______ of range techniques, or _________ (inc/dec) vigor as patient tolerates. You also want a ________ (shorter/longer) treatment
answer
end range increase vigor longer
question
What manual therapy technique might you utilize for a muscle restriction?
answer
muscle stretching hold/relax
question
What manual therapy techniques might you utilize for a joint restriction?
answer
manipulation grade 3 or 4 mob PPM
question
What manual therapy techniques might you utilize for capsular restriction?
answer
*grade 4 mob* *prolonged stretch* distraction w/ or w/o movement Note: if two *bold* are combined, patient irritability must be low
question
What manual therapy techniques might you utilize for extreme hypomobility or pain through ROM?
answer
PPM distraction
question
What are some mobilization treatment variables?
answer
-joint position -direction of technique -type of mobilization -intensity of mobilization
question
For mobilization techniques, some approaches advocate preliminary _______ therapy or _________ therapy prior to using these techniques. Australian approach utilizes ______ to determine this
answer
soft tissue modality SINS(S)
question
Examples of peripheral joint and spinal joint manipulation techniques (read)
answer
Peripheral: cuboid whip ankle - TCJ Hip Wrist MCP Spinal: -SIJ -Lumbar Thoracic (No cervical)
question
Remember to include appropriate ________ program following manual therapy
answer
exercise
Coding
Electronic Medical Record
Health Computing
Medical Terminology
Medical/Clerical Assisting
Pay For Performance
Using Computers
CH 1 EHR – Flashcard 73 terms
73 terms
Preview
CH 1 EHR – Flashcard
question
medical necessity
answer
treatment that is in accordance with generally accepted medical practice
question
electronic medical record
answer
computerized record of one physicians encounters with a patient over time
question
health information technology
answer
using computers and electronic communications to manage medical information. ex: sharing pt records with physicians outside the physicians own medical group, transmitting Rx to phamramcy's and ordering tests from an outside labs.
question
revenue cycle management
answer
oversight of the activities associated with a patient encounter to ensure that the provider receives full payment for services
question
certification
answer
nationally recognized designation that acknowledges that an individual has mastered a standard body of knowledge and meets certain competencies
question
patient examination
answer
an examination of a person's body in order to determine his or her state of health
question
pay for performance (P4P)
answer
provision of financial incentives to physicians who provide evidence-based treatments to their patients
question
ARRA
answer
federal act that provides financial incentives for adoption of electronic health records
question
practice management program
answer
program used to perform admin. and financial functions in a medical office
question
electronic health record
answer
computerized lifelong health care record with data from all sources
question
are practice management programs designed to manage patients clinical records?
answer
NO
question
what do integrated PM/EHR programs do?
answer
increase patient safety, improve quality of care and reduce operating costs
question
is the ambulatory care medical record a log of a patients hospitalizations?
answer
no, ambulatory is for outpatients not overnight stays
question
can medical records be used to protect physicians from accusations of malpractice?
answer
yes, because all documentation regarding the care and treatment of a patient will be in the records and can be used as a legal document.
question
when are the patients eligibility for insurance benefits verified?
answer
during the second step of the medical documentation and billing cycle
question
what program is used to monitor the status of claims that have been sent out to health plans?
answer
practice management programs
question
who maintains personal health records?
answer
the patient
question
who maintains EHR's?
answer
the physician
question
what is the federal law that protects patient's private health information, ensures coverage during job changes, and uncovers fraud and abuse?
answer
HIPAA
question
should diagnosis' be included in medical office records for patients?
answer
yes
question
what are some of the concerns when implementing an EHR in a physicians practice?
answer
1. changes to the practice's workflow 2. cost 3. the inability to share information due to lack of clinical standards
question
what is the purpose of managing the revenue cycle?
answer
cash flow
question
what are practice management programs used for?
answer
to manage payments from payers electronically
question
what type of health record contains information that may be entered by a number of physicians and other providers?
answer
EHR
question
A/R
answer
accounts receivable
question
EMR
answer
electronic medical record
question
HIE
answer
health Information exchange
question
HIT
answer
health information technology
question
NHIN
answer
national health information network - is a set of standard services and policies that enable the secure exchange of health information over the internet.
question
PM
answer
practice management
question
RCM
answer
revenue cycle management
question
list the 10 steps in the medical documentation cycle.
answer
1. preregister patient 2. establish financial responsibility 3. check in patient 4. review coding compliance 5. billing 6. check out patient 7. prepare and transmit claims 8. monitor payer adjudication 9. generate patient statements 10. follow up on patient payments and collections
question
health informatics
answer
knowledge required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine
question
Physician quality reporting initiative (PQRI)
answer
a medicare program that gives bonuses to physicians when they use treatment plans and clinical guidelines that are based on scientific evidence
question
meaningful use
answer
the utilization of certified EHR to improve quality, efficiency, and patient safety in the health care system
question
integrated PM/EHR programs
answer
programs that share and exchange demographic information, appointment schedules, and clinical data
question
medical record
answer
a chronological health care record that includes information that the patient provides, such as medical Hx, as well as the physician's assessment, Dx and TP
question
continuity of care
answer
coordination of care received by a patient over time and across multiple health care providers
question
medical malpractice
answer
the provision of medical services at a less than acceptable level of professional skill that results in injury or harm to a patient
question
diagnosis code
answer
a code that represents the physicians determination of a patients primary illness
question
procedure code
answer
a code that represents the particular service, treatment, or test provided by a physician
question
data wharehouse
answer
a collection of data that includes all areas of an organizations operations
question
data mining
answer
the process of analyzing large amounts of data to discover patterns or knowledge
question
record retention schedule
answer
a plan for the management of records that lists types of records and indicates how long they should be kept
question
must retention schedules comply with state and federal laws?
answer
yes
question
how long are physician's required to maintain medical records?
answer
for 7 years, some states including Hawaii require them to be maintained for 25 years
question
how long should laboratory pathology tests be retained for?
answer
10 years
question
what are the medical billers responsibilities?
answer
1. verify pt insurance info and eligibility 2. collect payments 3. maintain up to date info about a health plans billing guidelines 4. follow federal, state, and local regulations on maintaining the confidentiality of information about patients 5. abstracting info from patients records for accurate billing 6. billing health plans and patients 7. assist pts with insurance info 8. processing payments 9. maintaining financial records 10. updating forms and computer systems the practice uses for pt info. and health care claims processing
question
what are the eight facts that are documented in the medical record for an ambulatory patient encounter?
answer
1. patients name 2. encounter date and reason 3. appropriate history and physical examination 4. review of all tests that were ordered 5. diagnosis 6. plan of care, or notes on procedures or treatments that were given 7. instructions or recommendations that were given to the patient 8. signature of the provider who saw the patient
question
what are the four functions of a PMP that relate to manageing claims?
answer
1. creating electronic claims 2. monitoring clims status electronically 3. receiving notification of electronic payments 4. handling electronic payments
question
what are the responisbilities of the clinical staff?
answer
provide treatment for patients
question
what are the responibilities of the administrative staff?
answer
they manage the business aspects of health care, they work behind the scenes in a medical office and do not provide medical treatment or testing.
question
what its the goal of HIE?
answer
facilitate access to clinical information for the purpose of providing quality care to patients.
question
what are the 8 core functions of the EHR?
answer
1. Health Info & data element - pt demographic info 2. results management - access to current & past labs & tests results 3. order mgt - ability to send, receive & store orders for medications, tests and other services 4. decision support 5. electronic communication & conncectivitiy - ability for health plans/providers to access info 6. patient support 7. administrative processes - procedure codes and Dx codes enterd by physician in the EHR are transmitted electronically to PMP where coding specialist reviews them 8. reporting & population management
question
Electronic Funds Transfer (EFT)
answer
electronic payments sent directly to the providers bank
question
the info needed to create a claim is found on what 2 documents?
answer
patient information form and encounter form
question
ajudication
answer
when then payer receives the claim, it goes through a series of steps designed to determine whether the claim should be paid.
question
how is the A/R information important to a practice?
answer
helps practice decide whether to buy or lease new equipment, adopt new technology, expand to a larger office, add staff etc.
question
MIPAA
answer
Medicare Improvements for Patients and Providers Act 2008 - provides financial incentives to practioners who use e-prescribing, it enables them to transmit Rx electronically to a patients pharmacy
question
what does e-prescribing eliminate?
answer
RX errors caused by illegible handwriting and electronically checks for drug interactions and allergies
question
MIPAA requires e-prescribing by what year? If providers fail to do so, what happens?
answer
2011. They reduce payments to providers who fail to e-prescribe
question
what year did George W. Bush recommend greater use of IT in health care? And by what year should EHR be established by?
answer
2004 and 2014
question
REC - regional extensions centers
answer
offer information, guidance, training and support services to PCP who are in the process of making the transition to an EHR system.
question
integrated PM/EHR program
answer
can share and exchange demographic info., appointment schedules and clinical data, so info does not have to be entered twice, once in PMP and secondly in EHR.
question
what are the benefits of integrated PM/EHR programs?
answer
increases pt safety, improves the quality of pt care and reduces operating costs.
question
encounter AKA visit?
answer
the meeting of the patient and the physician or other medical professional for the purpose of providing health care.
question
preventative care
answer
care to keep diseases from occurring or to enable early detection and treatment. ex: routine physical, immunizations, screening tests and behavioral counseling.
question
acute care
answer
provided for illnesses with sudden onset that are time limited - not expected to continue for more than a few days or weeks, such as the recovery for a broken bone.
question
chronic illness
answer
Must be treated over the long term. On-going medical treatment for a lengthy period of time, in many cases for a life time. ex: heart disease, diabetes, asthma, AIDS.
question
Personal Health information (PHR)
answer
are private, secure electronic files that are created, maintained and owned by the patient
question
what do PHR's contain?
answer
current medicines and dosages, Health information, immunization records, allergies, medical test results, past surgeries, and family medical history.
question
compliance officer
answer
often the physician or practice manager - investigates and resolves all compliance issues pertaining to coding, billing, documentation and reimbursement.
question
is the administrative staff soley responsible for collecting payment for services?
answer
NO - all personnel both admin. and clinical play key roles. each must commuincate critical information to other staff members for reimbursement to occur.
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EHR Ch 1-6 54 terms
54 terms
Preview
EHR Ch 1-6
question
What is an EHR?
answer
Electronic Health Records are 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
What is Student Edition Medcin and what arethe four sections it is divided into?
answer
The point of care system we are using. It is divided into four functional sections: Top section is the tool bar Left pane in the middle is the nomenclature pane In the Right pane, the encounter note populates as the nomenclature is entered. At the bottom of the Medcin screen is for Entry Details for a current finding.
question
Why use an EHR?
answer
We have a more mobile society, where the patient is likely to see many clinicians for his care. To Save Lives by Reducing MEDICAL ERRORS! The federal government is providing incentives for changing to an EHR. This is in effect until 2015; then medicare reimbursement will deduct an increasing % of payments to those who have not changed to a certified HER.
question
Functional Benefits of an EHR
answer
Trend analysis Alerts Health maintenance Decision support Orders and results Administrative processes Population health reporting.
question
IOM Eight Core Functions
answer
Health information and data Result management Order management Decision suport Electronic communication and connectivity Patient support Administrative processes and reporting Reporting and population health
question
CPRI three key criteria
answer
Capture data at point of care Integrate data from multiple sources Provide decision support
question
HITECH Act
answer
Provides CMS incentives for provider to use a certified EHR
question
ONC
answer
Office of the National Coordinator Established Authorized Testing and Certification Bodies to certify EHR systems
question
Soap documentation
answer
Subjective: SX & HX Includes patient symptoms and history Objective: PX & TX Physical Examination and Test Results Assessment: DX The physicians diagnosis Plan: RX Includes physicians orders for treatments, meds, and further testing, lab orders, etc.
question
EHR Data Formats
answer
Images -Scanned documents -Diagnostic images (x-ray, CT, etc) Text Files -Imported word processing files (read by hand) Discrete Data -Fielded and Coded data -This type of data can be quickly searched by computer to create graphs, alerts, trending, etc
question
ehr Nomenclatures
answer
Coding systems designed to codify the details and nuances of the patient-clinician encounter. MEDCIN is a point of care nomenclature. Snomed-CT classifies and indexes medical information for research. LOINC is a nomenclature for use in a laboratory
question
Nursing code sets
answer
CCC is based on home care nursing NANDA-I nursing diagnosis and interventions NIC and NOC Nursing interventions & outcomes ICNP International nursing system Omaha System is community based nursing NMDS comparison of patient outcomes PNDS perioperative nursing PCDS has a stronger acute care origin
question
Cataloging images
answer
Images are scanned into the patient's chart. In order to connect the image to the patient's chart, the name, patient number, medical number, date and time, provider, etc. must be entered into the system with the image. This process can be automated by scanning barcodes containing the information.
question
Pac
answer
Picture Archival and Communication System This system is a separate system that stores the digital radiology pictures. When the patient's EHR is accessed by computer, it will access the link to PAC and the x-ray image will be seen on the patient's chart, even though it is not actually in the record. These images can also be remotely accessed by the patient's physician for viewing
question
HL7
answer
A nonprofit organization standard used by healthcare computer systems to exchange information. Many different code sets are used and HL7 can be used to translate and interface data into a main EHR system HL7 is very flexible and supports multiple coding standards, allowing data to be transferred to other healthcare facilities.
question
CDISC
answer
A subgroup of HL7 that with a specific focus on clinical drug trials.
question
v
answer
Digital Imaging and Communications in Medicine. Most widely used format for storing and sending diagnostic images, such as: Digital x-rays, CT scans, MRI's, ultrasound, angiography, endoscopy, laparoscopy, medical photography, and microscopy.
question
BIOMEDICAL DEVICES
answer
Many newer medical devices such as patient monitors, vital sign instruments, cardiac and arterial blood gas instruments can be wired or wirelessly transmit data to the patient's EHR.
question
sig
answer
Refers to the instructions for labeling a prescription. When the physician enters the sig into the record, the DUR software checks prescription against a of most known drugs; prescription, over the counter (OTC), and nutritional herb and vitamin supplements. The DUR software can create an alert when the drug can be affected by food or alcohol.
question
DUR or Drug Utilization Review
answer
Drug is checked against the patient's current medication list to determine if there is a conflict Ingredients are checked against the current meds duplicate therapy. Drug is checked against patient's allergies. The DUR checks previous diagnostic medical history for contraindications. Checks to ensure recommended guidelines for the drug are used.
question
Alerts
answer
Refers to a message or reminder that is automatically generated by the system. Alerts are based on programmed rules that alert when two or more conditions are met. Alerts can be programmed for just about anything
question
Formulary Alerts
answer
Alert the physician when your insurance will not cover the prescription, so that he may make a different choice if it is medically advisable. Formularies are lists of medications provided by your insurance company that indicates: Preffered Drugs Nonpreffered,Drugs, and Noncovered Drugs
question
Other types of alerts
answer
Lab orders not covered by Medicare Changes in values of certain blood tests, or when the result is outside of normal range. An alert may notify when preventative screening is due, An alert may send a reminder for immunizations
question
Decision Support
answer
The ability of the EHR to store or quickly locate materials relevant to the findings of the current case. Defined protocols Results of case studies Standard care guidelines from specialists, medical societies, or government organizations. Protocols are standard plans of therapy established for different conditions. Decision support also assists with medication dosing
question
ROS Review of Symptoms
answer
A way of organizing an exam by body systems starting from the head down. Located in the toolbar at the top of medcin. Changes symptoms from HPI into an ROS Symptoms from the chief complaint are entered from the HPI. The remainder of systems are reviewed in the ROS. Using auto negatives, the entire body can be documented quickly
question
FORMS
answer
Templates that display a desired group of findings in a consistent position every time. Electronic forms are one of the easiest ways to use an EHR and to increase speed of data entry. Allow you to organize questions in the order you would ask them. Forms also can allow entry of free-text notes right on the form
question
Auto-Negs
answer
This is really an Auto Normal feature
question
List
answer
Invokes a list manager window from which you can select and load a List. List Size: Increases or Decreases the number of findings in the displayed list. Sizes are 1-3.
question
CPOE
answer
-Computerized Provider Order Entry: One of the key features of an EHR that can improve quality of care, patient safety, and clinician efficiency. -Process Improvement Preventing lost orders Illegible handwriting Reduced drug errors Monitors for duplicate orders Reduces time to fill orders
question
CPOE improvements
answer
Automatically generates related orders Improves clinician productivity Easy access Reduces lag time Automated display of previous test results Better interpretation and detection of abnormalities for follow-up Access to consults and patient consents improves coordination among multiple providers
question
Lab Orders and Reports
answer
When an order for lab or other diagnostic tests is ordered, a unique ID called a requisition number is assigned. It may also be called an accession number. Many lab instruments are automated and enter results directly by electronic interface into the LIS, or Laboratory Information System.
question
LIS
answer
LIS assigns codes and records values for each component of the test and stored until being transferred electronically to the EHR, or printed on a paper lab result report. Results are complied into a report that includes the information from the original requisition, test codes, codes for each component of the test, as well as standard reference ranges for each associated with the actual value measured with the component, and any notes
question
Three areas of pathology
answer
Clinical Pathology: Uses chemistry, microbiology, hematology, and molecular pathology to analyze blood, urine, and other body fluids. Anatomic Pathology: Performs gross, microscopic and molecular examination of organs and tissues and autopsies of whole bodies. Surgical Pathology: Performs gross and microscopic exam of tissue removed from a patient by surgery or biopsy
question
Point of care testing
answer
Tests that are done outside the laboratory, at the patient's location. Example: Glucose monitoring. This point of care testing can be electronically transmitted to the EHR. In a hospital, it will usually be transmitted to the LIS, and then to the patient's EHR from there.
question
Reference Laboratories
answer
These are outside testing facilities that process tests for places that don't have their own laboratory, or for tests that are beyond the capabilities of the hospital laboratory
question
ABN
answer
Certain tests may not be covered by the patient's insurance and the patient must sign an acknowledgement that he or she has been advised that the test will not be paid by insurance. This form is an Advance Beneficiary Notice.
question
EHR Lab Result ADVANTAGES
answer
Reduction of turn-around time for results. Tracks results not yet reviewed by the physician Result reports of patient's current result, can also show his previous results. Trending is comparing the change of certain test components or vital signs over a period of time. Graphs can be easily created to show changes
question
search
answer
Performs automatic word completion Provides an extensive list of synonyms Identifies related findings and makes them automatically available in other tabs. Searches first in current tab; if no results, it will continue on to the next tab with results
question
prompt
answer
Short for \"prompt with current finding.\" Generates a list of findings that are clinically related to the finding currently highlighted. Shorter than the full nomenclature Contains only relevant findings Easier to read and navigate Functions in all tabs
question
RIS
answer
While many radiology departments are capable of receiving electronic orders, virtually all departments enter received orders into the Radiology Information System, and are handled electronically for the remainder of the process
question
Radiology Tests
answer
X-rays are now recorded on a special plate that captures the image digitally and store in PAC. CAT, or Computerized Axial Tomography uses x-rays to see into the patient's body and capture thousands of digital images. Also called CT. MRI, or Magnetic Resonance Imaging, uses magnetic fields and pulses of energy to create images of organs and structures inside the body that cannot be seen by x-ray or CAT scan
question
Radiology Tests and terms
answer
PET, or Positron Emission Tomography, combines CT and nuclear scanning using a radioactive substance called a tracer, which is injected into a patient's vein. A study is a set of related images interpreted by a radiologist. A hanging protocol refers to the number of images that simultaneously display on the radiologist's monitor.
question
Radiology Reports
answer
Usually dictated by the radiologist and typed by a medical transcriptionist, although some use speech recognition software that converts it into a typed report. Radiology reports are seldom available as a codified EHR record. Radiology observations that are codified are those related to the size and stage of tumors
question
Medication Orders
answer
Efforts to increase safety by hospitals include: CPOE Computerizing the pharmacy Positive identification systems to correctly match the medication with the patient. A pharmacy benefit manager An intermediary company that electronically checks the patient's formulary for the pharmacy system
question
Electronic prescriptions
answer
Prescription is issued and recorded in one step. Any problems with the prescription can be corrected immediately before being sent. Prescriptions are transmitted electronically to the pharmacy. Medication errors due to handwriting are reduced
question
Closed loop process for med safety
answer
Clinician writes prescription using CPOE. Prescription is checked and approved b y the pharmacist. Nurse receives order electronically and removes vial from medication-dispensing system. A handheld scanner device is used to read a barcode on the patient's armband to be sure the medication is being given to the right patient. Nurse scans the barcodes on each medication or intravenous solution and the computer program checks the electronic order and warns the nurse of any discrepancies. Nurse administers the medication to the patient Nurse documents the patient's chart. (Some systems repeat scan the armband, or scan the nurses badge to complete documentation electronically
question
The 5 rights of medication administration
answer
1 Right patient 2 Right time and frequency 3 Right medication 4 Right dose 5 Right route of administration
question
WHO
answer
WORLD HEALTH ORGANIZATION
question
ICD-9-cm 1900-1979
answer
International Classification of Diseases, 9th Revision, Clinical Modification Three volumes: Volumes 1 and 2 provide a listing and an index of diagnosis codes. Volume 3 lists codes for hospital inpatient procedures. Code consists of three characters, a decimal point, and up to two numerals. First three letters represent primary diagnosis. The ending numerals further refine the diagnosis specificity
question
Insurance Billing
answer
In 1989, the ICD-9-CM codes became required for insurance carriers to process claims. Allows for the use of multiple ICD-9-CM codes for a single procedure, indicating one code as the primary diagnosis, and the rest as secondary conditions for which the treatment was done
question
Specialized codes
answer
V codes represent circumstances other than disease or injury. E codes are for classification of external causes of injury or poisoning. ICD-10-CM has about twice as many codes. The US Dept of Health and Human Services has proposed it be adopted for billing in the US effective October 1, 2013
question
ICD-9-CM and the EHR
answer
Most EHR's contain an internal reference table that can add the ICD-9-CM codes automatically. The primary diagnosis is the reason the patient sought care. (chief complaint) Secondary diagnoses (or comorbidities) are classified as: POA Present On Admission, or HCA Hospital Acquired Condition
question
Multiple diagnoses
answer
Occur mainly in patients with ongoing or chronic conditions requiring regular visits. It is correct and appropriate to continue to use diagnosis codes from past visits as long as the patient continues to ave the illness or condition and that condition is clearly documented in the record
question
Rule-Out Diagnosis
answer
ICD-9-CM does not have specific codes or modifiers for \"possible, probable, suspected, or rule-out\" conditions. Services performed for in-patients, support the concept of \"rule-out\". Guidelines for out-patients, are not supported, therefore, the insurance claim for an outpatient visit should not be coded with a diagnosis for the suspected disease
Brand Name Drug
Chronic Back Pain
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Electronic Health Records- Exam 1 37 terms
37 terms
Preview
Electronic Health Records- Exam 1
question
Which of the following is true about the login you use for the Student Edition software?
answer
It is unique to you.
question
Which of the following is the Medcin tab that is used for \"treatments\"?
answer
Rx
question
Which of the following statements about imported text data is false?
answer
The text data is codified by the EHR once it has been imported.
question
The Sx tab on the Nomenclature Pane is associated with which component of the SOAP format?
answer
Subjective
question
Which of the following is not an example of a function menu in the Student Edition software?
answer
Encounter
question
When using the Student Edition software, what is the first step in every encounter once you have logged in?
answer
Selecting a patient
question
Which of the following is an example of a digital image that may be part of an electronic medical record?
answer
Annotated drawings
question
Which of the following is an example of trend analysis provided by an EHR?
answer
A graph showing a patient's cholesterol levels over time
question
You receive a letter in the mail from the pediatrician saying that your child is due to receive certain immunizations. This is an example of which functional benefit of codified EHR data?
answer
Health maintenance
question
Why is the first item in each drop-down list within the Entry Details fields a blank?
answer
To clear certain Entry Details fields
question
A text file would be produced for upload to an EHR in which of the following examples?
answer
A medical transcriptionist types exam notes using a word processor.
question
A patient tells you that he has been having back pain for over a month. Later in the exam, he remembers the pain seems to be getting worse. How would you record this finding information in the EHR?
answer
Back pain, chronic/recurring, episodes recently worse
question
What is the main purpose of an EHR system that is based on the MEDCIN nomenclature?
answer
To document clinical notes in a codified electronic medical record
question
Which of the following is the Medcin tab that is used for \"tests performed\"?
answer
Tx
question
Which of the following best defines the term eligible professional?
answer
A health care provider who is considered entitled to receive incentive payments under the HITECH Act.
question
Which of the following is an example of a result finding?
answer
Normal urine protein
question
Both the IOM and CPRI share which of the following EHR criteria recommendations?
answer
Provision of decision support
question
Which of the following certifies an EHR system?
answer
ONC-ATCB
question
Which of the following statements is not true about an encounter note?
answer
It is a longitudinal record of the care a patient has received.
question
In which section of the Student Edition software is the Hx tab located?
answer
Medcin Nomenclature Pane
question
Which of the following is not considered part of the workflow in a medical office that uses an EHR system?
answer
The physician dictates her exam notes at the conclusion of the patient encounter
question
Your medical office is implementing an EHR system and needs to add numerous paper charts into the new document/image system. The best course of action would be to:
answer
import the word processing files from any transcribed dictation as text records.
question
One drawback of using an EHR on a tablet PC that is not a problem on a laptop is that it:
answer
lacks a keyboard.
question
Which of the following is considered an optional, rather than a core, meaningful objective for hospitals when fulfilling the CMS meaningful use criteria?
answer
Drug formulary checks
question
You are viewing findings in the Medcin Symptoms tab and notice that \"facial twitching\" has neither a small plus sign nor a small negative sign beside it. What does this mean?
answer
This is the most specific finding available for symptom.
question
Jenna has a penicillin allergy. Which of the following alerts in an EHR would detect this allergy?
answer
DUR
question
Which of the following statements about electronic health records is true?
answer
The HITECH Act is promoting the widespread adoption of electronic health records
question
Which of the following is a characteristic of an EHR system used by a medical office?
answer
It is the principal electronic medical record.
question
Where within the Student Edition software can you locate a finding associated with its appropriate ICD-9-CM code?
answer
Outline View
question
An insurance billing code represents a:
answer
service that was rendered.
question
Which of the following statements is true about discrete data that is stored in an EHR system?
answer
It requires little storage space.
question
You are trying to locate the patient Robert Smith in the Student Edition Patient Selection window. Which of the following would be the quickest way to locate his record?
answer
Entering the patient's last name, followed by R
question
Which of the following is the best definition of electronic health records?
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
An alert that warns a physician that a brand name drug is not covered by a patient's insurance plan is an example of a(n):
answer
formulary alert.
question
The ONC developed which of the following strategies to meet their goal of informing clinical practice?
answer
Promoting EHR diffusion in rural and underserved areas
question
Which of the following would not be considered a benefit of patient-entered data?
answer
The patient can review and make corrections to previous entries made by medical staff.
question
Which of the following is not an advantage of the free-text entry window?
answer
The text entered in this window is stored as fielded data.
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Medical Terminology – Health Information Technology Word List 31 terms
31 terms
Preview
Medical Terminology – Health Information Technology Word List
question
health information management (HIM)
answer
the management of patient healthcare data of all types
question
information technology
answer
the process needed to assimilate, organize, maintain, and store patient healthcare data
question
health informatics
answer
a branch of health information management that uses computer systems to gather, organize, maintain, and store patient healthcare data
question
traditional health record
answer
a medical chart stored and maintained in paper format
question
electronic medical record (EMR)
answer
digitally stored and accessed patient records that allow real-time communication, reporting, and recordkeeping through electronic transmission; also called electronic health records (EHRs) or computer-based patient records (CPRs)
question
hybrid health record
answer
a medical record that incorporates elements of paper-based records and electronic records
question
alphabetical filing system
answer
a method of organizing health records according to the patients surname
question
numerical filing system
answer
a method of organizing health records according to a unique patient identification number
question
alphanumeric filing system
answer
a method of organizing health records by combining the first two letters of the patient's surname with a numerical identifier
question
out guide
answer
a card placed in a collection of paper files to indicate that a file has been removed
question
requisition
answer
a written request for a health record
question
quality management
answer
the process of planning, controlling, and improving the quality of a product or system
question
deficiency slip
answer
a report generated to notify staff that a medical record is missing required information
question
index
answer
a database that contains pertinent healthcare information that can be used for research, healthcare quality control, or statistical purposes
question
master patient index
answer
the primary index used for HIM record keeping, which includes a unique record for each patient within a healthcare organization
question
physician index
answer
a database that records the physician associated with each patient, diagnosis made, and procedure performed at a healthcare organization
question
registry
answer
a database of information concerning births, deaths, admissions, and discharges
question
Centers for Disease Control and Prevention (CDC)
answer
a United States government organization that seeks to promote healthy behaviors and the prevention of disease, injury, and disability
question
World Health Organization (WHO)
answer
a global organization, created by the United Nations, that provides global leadership on health, health research, and health policy
question
cancer and trauma registries
answer
compilations of healthcare data on different types of cancers and traumatic events
question
birth certificate completion
answer
the process of fully completing an infant's birth certificate
question
statistical and research services
answer
data analysis services provided for health information professionals who are conducting medical studies of tracking diseases
question
medical transcription
answer
the process of creating a text-based medical record from a voice recording
question
health data security
answer
the process of ensuring that medical records are unaltered, readily accessible, and used legitimately
question
Health Insurance Portability and Accountability Act (HIPAA)
answer
a law governing the portability of health insurance when workers change jobs, the standards for electronic healthcare transactions, and the security and privacy of health data
question
privacy rule
answer
a part of HIPAA that outlines standards for maintaining patient confidentiality
question
breach of confidentiality
answer
disclosure of patient information without prior written consent
question
protected health information (PHI)
answer
any information about a person's health, healthcare, or payment for health services that can be linked to a specific patient
question
Department of Health and Human Services (HHS)
answer
a United States government organization that establishes guidelines for health information management compliance
question
Office of the Inspector General (OIG)
answer
investigates abuse, fraud, waste, and mismanagement within a government organization
question
American Health Information Management Association (AHIMA)
answer
a not-for-profit professional organization serving the education, credentialing, networking, and advocacy needs of health information management (HIM) professionals
Electronic Medical Record
Health Computing
Medical Terminology
Medical/Clerical Assisting
Subjective And Objective
MOP Chapter 14- Medical Records Management – Flashcards 25 terms
25 terms
Preview
MOP Chapter 14- Medical Records Management – Flashcards
question
What is the most important ethical reason to maintain accurate medical records?
answer
Continuity of patient care
question
What filing tool could you use to track a patient's chart which has been removed from the storage area?
answer
Out guides
question
How should you correct an error in a medical record?
answer
In red ink, draw a red line through the error, with the word CORR or Correction with your name/initials and date
question
What type of coding systems are commonly used in ambulatory care centers?
answer
Alphabetic, numeric, and subject
question
What is the most important information to put on an out guide?
answer
Who has the file, Where the file is, When the file was taken out, When the expected return date is
question
The greatest bulk of information generated by medical facilities comes from what?
answer
Patient medical records
question
Why would you use cross-reference filing?
answer
To find a specific record that may be filed under more than one name/sunject
question
What do we call a filing method that serves as a reminder for future actions?
answer
Tickler File
question
What do we call the process of sorting through records and removing those that are not active?
answer
Purging
question
When using a tickler file, what should be listed on the reminder?
answer
Patient name, Tickler date, Required action, Any additional relevant information
question
What method of arranging charts uses a page that lists vital identification data, immunizations, allergies, medications and problems?
answer
Problem-Oriented medical records (POMR)
question
What do we call records that need to be readily accessible for retrieval of information?
answer
Active files
question
What is the primary use of out guides?
answer
To help track charts
question
Where would you file information for non-patient services?
answer
Miscellaneous
question
What's the legal standard if there is no written record of a temperature, a visit, a history, physical, or a lab report?
answer
If it isn't charted, it didn't happen
question
What format should be used for a patient's name on a medical chart?
answer
Indexing- Last name, First name, Middle name
question
What would you need to consider when choosing a patient filing system?
answer
How the charts will primarily be used, The number of documents filed, If the information needs to be tracked by others
question
What type of filing systems would be most appropriate when you have a large amount of patients?
answer
Numeric system
question
What type of filing cabinets is most appropriate for an office with a large record system?
answer
Movable File Units
question
What type of medical record format contains a problem list?
answer
SOAP/ER
question
Movable file units require how much space compared to vertical or lateral files?
answer
Much less
question
What do we call it when EMRs from multiple sources are combined into one database for a patient?
answer
EHRs (Electronic Health Records)
question
President George Bush's 2004 Health Information Technology Plan included the goal that most Americans would have electronic health records by what year?
answer
2014 changed 2015
question
Who is least likely to use EMRs?
answer
small offices with one provider
question
What are the HIPAA standards in regards to EMRs?
answer
-Computers, network hubs and servers must be secure from intrusion -Users who access medical information are to be identified and updated regularly -Firewalls and antivirus measures must block unauthorized access -Passwords are not to be easily guessed, must be securely stored, and should be changed no fewer than every 90 days -Passwords are to be hidden when entered and are not shared with anyone -The number of invalid entries to access information must be limited -Computer screens are to be out of view of unauthorized individuals -Screensavers are used for further protection when there is no computer activity
