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health records ch 1

electronic health records

one of the first physician to keep patients records is chunyu yi
medication, allergies list, immunization records, lab and pathology reports, surgical and hospital records, history and physical assessment findings, progress notes, and imaging test results are considered health information
health information and administrative information and legal documents are content of an electronic health record
patient info, referral and consultation letters, insurance info and claims status, billing info, appointment history, diagnosis and procedure codes, and name of emergency contact person are considered administrative information
records releases, informed consent documents, HIPPA forms, advanced directives, living will, insurance authorization forms, and healthcare power of attorney forms are considered legal documents
an individual who is responsible for inputting patient info into the medical record is called documenter
who is the main documenter the physician
EHR electronic health record
IOM institute of medicine
the cardinal function is to be a central repository for the patients health info from a variety of sources is what core function health info and data management
what core function is in instituting an EHR system that should make test results easily accessibe results management
what core function gives the ability to order test and prescribe medications electronically reducing errors and lowers costs order management
what core function is the EHR software should offer features that help clinicians manage patient care according to evidence-based treatment guidelines decision support
what core function is the chief advantage of an EHR system is that it allows all providers and institutions involved in a patients care to communicate and share data efficiently, thereby improving the quality of the patients care electronic communication and connectivity
what core function allows many EHR systems have tools for patient education, such as wound care instructions or guidelines for self-monitoring of blood glucose patient support
what core function allows billing and scheduling can be handled electronically administrative processes
diagnoses of infectious diseases can be reported confidentially to public health authorities, and researchers can access EHR database to gather epidemiologic statistics reporting and population health
HIT health information technology
CPOE computerized physician order entry
CDS clinical decision supprot
a set of patient-centered tools embedded within EHR software that can be used to improve patient safety, ensure that care conforms to published protocal for specific conditions, and reduce duplication or unnecessary care and its associated cost is called clinical decision support (CDS)
an EHR function that allows a physician or other prescriber to order medications and test using an automated format; it can reduce prescribing errors, delays, and duplication and simplify inventory and billing processes computerized physician order entry (CPOE)
the ability of separate EHR systems to share information in compatible formats is known as interoperability
what professional organization for medical assistants searching for professional development, continuing education, approve programs, and certification information for medical assistants american association of medical assistance (AAMA)
what is the name of the nonprofit certification agency and professional membership association representing more than 41,000 individuals in allied healthcare american medical techmologists (AMT)
a specialized graphical element that toggles on and off and is used when only one response is appropriate, since two of these buttons can't be depressed at the same time is known as raido button
labels used to indicate a patient's behavior, current location, or disposition is known as contexet specific
the space allowed on a form for specific numeric or text data is called the field
a specialized graphical element tat toggles on and off and is often used when more than one response might be appropriate is called check box
the amount of time records must be kept in storage by a medical office is known as retention
a secondary, related set of options displayed by holding the cursor over an entry on the main menu or by clicking to expand a list is called category list
to cancel the selection of a passage of text by removing the highlighting is known on deselect
a form used to gather data about the patient, including contact information, health history, current health status, and chief complaint is called patient informatio sheet
an individual or entity other than the patient (first party) or the provider (the secondary party) that is financially responsible for a portion of the patient's healthcare bills is known as third-party payer
software used in a medical office to accomplish administrative (non clinical) tasks, including entry of patient demographics, record-keeping for insurance and other billing transactions, appointment scheduling, and advanced accounting functions is called practice management software
Created by: maryce



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