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Terms in this set (61)Health care providers, health plans, and electronic claims clearinghouses that engage in certain electronic transactions are known as ________________. -covered entities The HIPAA Privacy Rule applies to health information created or maintained by covered entities. Which of the following is a computerized report that lists all procedures ordered but with no results on record? -Exception report An exception report is a computerized report that lists all procedures ordered but with no results on record. This report facilitates the follow-up. All of the following are types of electronic signature except: -Image Image is not a type of electronic signature. The three types of e-signatures commonly used in EHRs are the digitized signature, the token signature, and the digital signature. Which one of the following terms refers to health information that the patient stores electronically on a computer or on a secure central Internet site? Personal health record (PHR) Correct. A personal health record (PHR) is health information that the patient stores electronically on a computer or on a secure central Internet site. In comparison to paper medical records, EHRs contribute to cost savings by: allowing automated formulary checks by health plans. Correct. EHRs contribute to cost savings by enhancing communication with other clinicians, labs, and health plans through automated formulary checks by health plans. Unlike a paper-based medical record, a patient's EHR: can be used by more than one staff member at the same time. EHRs store various types of information, just as paper-based records do, except with an EHR, that information is: linked and cross-referenced. What is the difference between a patient's paper chart and an electronic health record? -The EHR is stored and accessed using a computer. Correct. The same information found in a patient's paper chart is found in an electronic chart; however, electronic records are stored and accessed using a computer. Unlike paper-based medical records, EHRs provide the ability to: -identify who has entered and accessed patient information. Correct. EHRs provide the ability to identify who has entered and accessed patient information. The Office of the National Coordinator for Health Information Technology (ONC) was established to encourage the use of technology to accomplish all of the following except: -Increase Medicare costs Correct. The Office of the National Coordinator for Health Information Technology (ONC) was not established to increase Medicare costs but to reduce expenditures. The Congressional Budget Office (CBO) anticipates that approximately _____ percent of doctors and _____ percent of hospitals will be using comprehensive electronic health records by 2019. -90; 70 The Congressional Budget Office (CBO) anticipates that approximately 90 percent of doctors and 70 percent of hospitals will be using comprehensive electronic health records by 2019. A characteristic of certified EHR technology is: -it is secure and can maintain data confidentially. Correct. Certified EHR technology helps providers and patients be confident that the electronic health information technology (IT) products and systems they use are secure and can maintain data confidentially. All of the following are criteria for meaningful use of EHRs except: EXCEPT --> improve payment of bills. EHR CRITERIA= Meaningful use criteria are grouped into five patient-centered areas that relate to health care priorities: improve quality, safety, and efficiency; engage patients and families; improve care coordination; improve public and population health; and ensure privacy and security for personal health information. Which one of the following offers financial incentives for providers who adopt EHR? -Health Information Technology for Economic and Clinical Health Act (HITECH). The Health Information Technology for Economic and Clinical Health Act (HITECH), which is part of the American Recovery and Reinvestment Act of 2009 (ARRA), includes financial incentives for providers who adopt EHR and demonstrate its use in ways that can improve quality, safety, and effectiveness of care. The goal of providing funding through the HITECH Act is to -encourage providers to adopt EHR sooner than they otherwise would. Correct. The HITECH Act provides financial incentives for providers who adopt EHR, and the goal of the funding is to encourage providers to adopt EHR sooner than they otherwise would. What does an electronic medical record store that a practice management system doesn't? Patient clinical information Correct. A practice management system does not store clinical information, aside from that used for billing, such as diagnostic and procedure codes. When fully implemented, what can an EHR system do that a practice management system cannot? Network with offices of other health care providers Correct. An EHR system manages medical records of individual patients and, when fully implemented, networks with offices of other health care providers to share information regarding specific patients. EHRs enable providers to review medications prescribed by other providers in order to: -avoid duplication or drug interactions Correct. EHRs enable providers to review medications prescribed by other providers, so that duplication or medication interactions can be avoided. EHRs enable providers to have easy access to a patient's _____, which can result in the provider more quickly identifying a problem or risk factor. -medical history Correct. EHRs enable providers to have easy access to a patient's medical history, which can result in more quickly identifying a problem or risk factor. The results of some tests performed in the medical office, such as blood test and digital X-rays, can appear in the EHR: -immediately Correct. Blood tests and digital X-rays can appear in the EHR immediately. EHRs help providers to complete documentation more quickly, more consistently, and in more detail than paper-based documentation by: -letting them select information from preprogrammed lists. Correct. EHRs help providers to complete documentation more efficiently by letting users select information from preprogrammed lists. Most EHR programs have drop-down menus or selection lists that allow the user to choose information or symptoms. In 1999, the Institute of Medicine reported that some preventable medical errors are caused by: -indecipherable handwriting Correct. In 1999, the Institute of Medicine reported that some preventable medical errors are caused by indecipherable handwriting. It was a problem that would be eliminated if health care providers made their entries electronically. _______________ own the information in medical records, but the facility that created the information owns the physical or electronic record. -patients Correct. Patients own their own information in their medical records, but the facility that created the information owns the physical or electronic record. The patient has the right to control under what circumstances, and with whom, the medical record is shared. The medical record is a(n) _______________document. -legal Correct. The medical record is a legal document and a permanent record. ________________established that the patient owns the information in the medical record. -HIPAA Correct. The Health Insurance Portability and Accountability Act (HIPAA) established that the patient owns the information in the medical record and has the right to control under what circumstances, and with whom, it is shared. The medical record can be ____________by the courts as evidence. -subpoenaed Correct. The medical record is a legal document. Who must explicitly authorize the release of a patient's records in writing for any use aside from treatment, payment, and operations? -the patient Correct. Patients consent to the use and disclosure of personal health information for treatment, payment, and operations as defined by HIPAA. For all other uses, patients must explicitly authorize release of their records in writing. Federal law provides special protection for release of what type of information in medical records? -substance abuse treatment records As new problems and diagnoses are identified, they are noted on the ________ of the POMR. -problem list Correct. The problem list helps the health care provider to identify trends in the patient's medical history or emerging diagnoses. What part of the POMR consists of the physical examination, the patient history, and the results of baseline laboratory or diagnostic procedures? -Database Correct. A POMR has four parts: database, problem list, plan, and progress notes. The database consists of the physical examination, the patient history, and the results of baseline laboratory or diagnostic procedures. In a source-oriented medical record, information in each section is maintained in __________. -reverse chronological order. Correct. In a source-oriented medical record, patient information is organized in sections for various purposes, such as history and physical, insurance, medications, and laboratory. Information in each section is maintained in reverse chronological order, with the most recent information seen first. The ___________________is a very important part of the medical record because it tells what is intended for the patient. -treatment plan Correct. Each treatment plan should have a title and should reference the problem number with which it is associated. What is the functional aspect of POMR charting found at the front of the chart? -Patient problem list What information gathered from the patient is usually the same as a chief complaint (CC)? -subjective Correct. Subjective information includes the things that the patient believes he or she is seeing a physician for. Vital signs, weight change, fevers, blood work, physical examination results, and any other observable and measurable data are considered what type of information in SOAP charting? -objective In SOAP charting, the assessment is the physician's preliminary ________________. -diagnosis Correct. Assessment is one of the four distinct parts of SOAP charting. What two charting methods can be combined in one chart? -POMR and SOAP Correct. The POMR and SOAP combination makes for a very concise, clear set of information on any patient. An autopsy report is a(n) _____________report generated after a patient's death to determine the cause of death. -pathology Correct. The pathology report is generated by the pathologist as the result of examining tissue and organs removed during a surgical procedure or an autopsy. What form would be used to request a list of herbal medications and recreational drugs used by the patient? -family and medical history Correct. The family and medical history information should include the patient's current prescription, herbal, and over-the-counter medications. The __________form should request the patient's occupation, marital status, number of children, and emergency contact information. -patient registration Correct. The patient registration form also includes the patient's full name, address, contact information, date of visit, age, date of birth, Social Security number, driver's license number, medical insurance information, and person responsible for payment. What does an operative report describe? -surgical procedures Correct. The surgeon is expected to dictate this report as soon as possible, preferably immediately after the procedure is completed. In what type of file storage is a color-coded system for visual recognition of files often used? -lateral Correct. Lateral files are set up with shelves that allow files to be easily pulled off them. What type of file storage system is heavy and space consuming? -vertical Correct. Vertical files are set up with two to four stacked pullout drawers holding up to a hundred files per drawer. Which of the following file storage systems is useful for storing books and journals? -movable Correct. This system is useful for books and journals, because the floor can be reinforced when the track is installed. The main purpose of the _________on the file is to identify what is in the file. -label Correct. The label also can include a color-coded stripe that can be used for other purposes, such as identifying the primary care physician. In alphabetic filing, which of the following are disregarded for filing but placed in parentheses after the name? -titles and initials Correct. For example, Dr. Beth Ann Williams is indexed as Williams, Beth Ann (Dr.). The key to what type of filing is to divide the names and titles into units (first, second, and third)? -alphabetic Correct. The unit is the portion of the name that is used for filing or indexing purposes. In what type of filing system are names filed: last name, first name, and middle name? -alphabetic Correct. Each letter in the name is a separate unit. Example: Krause, Marvin K. is placed before Krause, Marvin L. In what numeric filing system does the patient receive a different medical record number for each hospital visit? -serial-number Correct. With the serial-number filing system, the patient acquires multiple records that are stored at different locations. Which of the following numeric filing methods requires that all records be kept at the same location? -unit-number Correct. A unit-number filing system is most commonly used by hospitals. A number is assigned to patients the first time they are seen or admitted to a hospital. All other hospitalizations or hospital visits use the same number. __________ filing is based on the last two digits of the ID number and evenly distributes the files within the entire filing system. -terminal-digit Correct. Filing using terminal digits requires dividing the files into a hundred primary sections, starting with 00 and ending with 99. Each _________ varies somewhat on the legal time limits (statute of limitations) to keep records and documents. -state Correct. At a minimum, you should retain records until the statute of limitations expires. Cross-referencing can be a simple but useful tool for avoiding ______________. -misplaced records Correct. One of the most time-consuming and frustrating activities relating to medical records is locating a misplaced file. A miniaturized photograph of medical records that can be used for efficient long-term storage is -microfilm Correct. Medical records that need to be stored long-term can be transferred to microfilm, which is a miniaturized photograph of the records. How long does the American Medical Association recommend keeping medical records? -ten years Correct. In selected circumstances, you might consider saving the more complex records or those records with known serious patient problems for a longer period of time. Unlike paper-based medical records, EHRs provide the ability to: -identify who has entered and accessed patient information. Correct. EHRs provide the ability to identify who has entered and accessed patient information. EHRs allow a patient to view test results and physician comments online, but such accessibility must be made: -through a secure patient access portal. Correct. EHRs allow a patient to view test results and physician comments online, but such accessibility must be made through a secure patient access portal to comply with HIPAA. One advantage in work flow for electronic health records compared to paper medical records is __________. -point of care documentation. Correct. With an EHR system, health care providers can document the patient encounter in the examination room and enter information into the computer while the patient is present. This improves the quality of documentation and reduces errors. In order for a medical assistant to enter orders into the computerized physician order entry system, the medical assistant must be -credentialed. Correct. Only licensed health care professionals, including credentialed medical assistants, are allowed to enter orders into the CPOE system. "Credentialed" means having obtained a certification or registration from a national credentialing organization other than the educational institution and employer. With a computerized physician order entry, all of the following can be ordered using the computer except: -exam room supplies Correct. Computerized physician order entry (CPOE) is the ability of providers to order tests, prescriptions, lab work, and referrals using the computer. Exam room supplies can be ordered using the computer, but not through the CPOE system. The Office of the National Coordinator for Health Information Technology (ONC) does not encourage the use of technology for what purpose? NOT= To increase Medicare costs Students also viewedMA Admin CH. 19 HW34 terms Stacy_Yang40 MA Admin Ch. 15 HW36 terms kayphilli MA Admin Ch 13 HW61 terms kayphilli MA Ch. 13 The Medical Record Exam57 terms Tanya_kovalyov Sets found in the same folderMA Admin Ch. 11 HW39 terms kayphilli MA Admin Ch. 3 HW57 terms kayphilli MA Clinical Ch. 6 HW51 terms kayphilli MA Chapter 34 Vital Signs Study Guide76 terms nickmanning08 Other sets by this creatorBASIC MT16 terms moriahoc MOD 6-Rx F/C20 terms moriahoc itphlebotomy22 terms moriahoc RMA practice STUDY----34 terms moriahoc Recommended textbook solutionsPharmacology and the Nursing Process7th EditionJulie S Snyder, Linda Lilley, Shelly Collins 388 solutions
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Which statement is included in the Office of the National Coordinator for Health Information Technology's ONC's mission?The mission of ONC
According to ONC, this last mission aims, among other things, to: improve the quality of healthcare while reducing costs; improve the coordination of care and information among hospitals, labs, physicians and other healthcare organizations; ensure that personal health records (PHR) remain secure; and.
Which are the responsibilities of the Office of the National Coordinator?The Office of the National Coordinator for Health Information Technology (ONC), a staff division of the U.S. Department of Health and Human Services (HHS), is the lead agency charged with formulating the Federal Government's health information technology strategy and coordinating federal health IT policies, standards, ...
What is the main focus of health information technology quizlet?The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing and use of health care information, data and knowledge for communication and decision making.
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The Office of the National Coordinator for health information Technology Quizlet
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