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61 Cards in this Set
- Front
- Back
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Lost or misfiled records Mishandled patient messages Inaccurate and illegible documents Mislabeled or illegible lab or medication order |
Four errors that stem from communication problems
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PHR, EHR, or EMR PHI that is electronic version of the comprehensive medical history and record of lifelong health & is collected and maintained by the patient; |
PHR
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PHR, EHR, or EMR Conforms to national interoperability standards |
EHR
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PHR, EHR, or EMR Not a legal record |
PHR
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PHR, EHR, or EMR Used by a single healthcare organization |
EMR
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PHR, EHR, or EMR .....covered by HIPAA |
All
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What are 3 advantages of EHR?
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Fewer lost medical records Chart availability outside of office hours More efficient transfer of records |
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What are 3 disadvantages of EHR?
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Costly Staff training requirement IT staff may be needed |
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What is the main reason medical practices are not implementing EHRs?
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Cost
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True/False All EHR programs will be the same. |
False
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True/False The basic rules for working with an EHR are the same as for a paper record. |
True
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True/False Once you make a mistake in an EHR, there is nothing you can do to correct it. |
False
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Electronic Scheduler Report Generators Tickler Files |
3 functions of EHR programs
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Computerized records-files that need periodic attention Can alert staff members about patients who are due for yearly check ups & patients who require follow up care |
Tickler files
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This can provide ---Multiple users @ any time ---Depending on software-can find a patient's appointment by patient's name/look up record Better than paper apt book b/c paper apt book only allows 1 user at a time and patients become frustrated & increase wait time |
Electronic scheduler
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sends an alert for follow up care
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Tickler file
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May send a reminder to the patient
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Electronic scheduler
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Checks insurance coverage
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Eligibility verification
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Allows for electronic claims to insurance companies
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Billing & coding
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Office statistics
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Report generator
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Flags allergies
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Prescription writer
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Submits orders to the lab
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Ancillary order integration
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Make an appointment or pay a bill
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Patient access
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When medical records are kept electronically, it is essential that the facility have policies in place to ensure .....&......of records
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security & confidentiality
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When documenting by hand/electronically, ....is important |
accuracy
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This is essential and can help protect the patient and the office
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Careful key entry
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......should be in place so that electronic files are ....up on a regular basis
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Processes; backed
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..........software programs may be .....to suit a specific specialty & style of a physician's office
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EHR; customized
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What does the use of access codes enable medical practice do?
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Access codes can be set to limit a person's access to a medical record based on his/her job description. (Can also keep track of who accessed the record and when)
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An electronic of health-related information for an individual patient
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Electronic medical record
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True/False The same rules apply with EHR as for paper-based medical records when initiating or documenting in a patient's electronic health record |
True
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Reassuring others about EHR confidentiality Be .......of the office EHR program and never display a negative attitude about it Assist in preparing .....information for the patients regarding the EHR program |
knowledgeable; written
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Reassuring others about EHR confidentiality Show the patient his ....., and explain how the information is entered, maintained, and kept secure ......& be able to explain the backup process for the EHR program |
EHR; Understand
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Reassuring others about EHR confidentiality Understand the office access policy as it pertains to ....and explain it to the patients |
HIPAA
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The over-all point is that new technology will not necessarily replace old technology, but it will date it. By definition. Eventually, it will replace it!
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Steve Jobs
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It is .....to delete information from the patient record, as it is a legal record of the business activities for the facility
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unlawful
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Erroneous or incorrect entries must remain in record with...
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new or correct data appearing as an addendum/correction note
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HIM personnel will stay strictly involved with the ..... of patient records
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administration
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An environment where there is an electronic records system of some level, but paper records are also maintained
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hybrid record
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Another responsibility for HIM personnel is
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performing quality checks on records and assembling requests for a copy of the legal health record in response to accreditation reviews/subpoenas
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An index that requires great attention to detail to preserve accuracy and completeness of patient information
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Master Patient Index
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Support treatment Seek reimbursement for services rendered Subpoenas/law enforcement inquiries Public health law-STDs |
Certain circumstances to release PHI without special authorization
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Is an authorization to release a patient's PHI transferrable?
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No; no one may re-release the same records even if authorization has not expired
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In a smaller environment, your role in updating software may range from.....to....
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extensive -minimal
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Since 2006,.....has been certifying EHR products
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CCHIT
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This offers financial incentives for providers & hospitals to show they are using certified EHR technology in a meaningful way
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CMS
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Medical errors in the US are calculated to be the...leading cause of death
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8th
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Which government insurance plan offers EHR incentive programs?
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Medicare & Medicaid
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What does the term EP stand for?
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Eligible provider
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What function of the EHR program will be most helpful to the administration when reviewing the financial health of the practice?
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Report generator
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What function of the EHR program would be most helpful to the staff who schedules appointments for patients with specialists?
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Insurance verification
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How many identifiers are required to correctly identify a patient's EHR?
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at least 2
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What is mandated in step 2 of "meaningful use" of EHRs for Medicare or Medicaid patients?
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Sending & receiving clinical information electronically
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The goal of the presidential executive order signed in Aug 2006 was to give most Americans access to electronic health records by year
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2014
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If the computer is down the day's scheduler is not accessible
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Disadvantage of electronic scheduler
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What must a physician demonstrate in order to receive a financial incentive from the federal government for converting to an EHR system?
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Meaningful use of EHR program
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The greatest concern of electronic health records is
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protecting the confidentiality of patient records
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Communication problems that lead to medical errors don't include
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improper telephone etiquette
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What percentage of the US gross national is accounted for by healthcare costs? |
15%
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True/False PHRs may be stored and maintained on secure Internet sites |
True
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Which of the following is not likely to be a required field in your EHR software's form to be completed for each new patient?
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Patient DL
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