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EHR

Electronic Health Records

QuestionAnswer
The use of outdated systems has been cited as a cause of financial waste in the American health care system. T or F True
Patients purchase medical liability insurance to protect themselves from being victims of medical errors. T or F False
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires individuals covered by Medicare to participate in a prescription drug program. T or F False
The users of electronic health records are health care professionals. T or F True
A personal health record (PHR) contains admission and discharge summaries. T or F False
A physician office and an outpatient clinic are examples of ambulatory care facilities. T or F True
Health information exchanges (HIE) are nationwide health care networks. T or F false
Electronic health record systems are inexpensive and easy to learn. T or F False
Electronic health records are less prone to privacy and security issues than are paper-based records. T or F False
Certification in a field of study represents mastery of a body of knowledge. T or F True
The delivery of appropriate and consistent care to an individual over the course of time Continuity of care
A computer-based communication system that allows prescriptions to be transmitted electronically from physician to pharmacist Electronic prescribing
A set of commonly agreed-on specifications Standards
A computerized lifelong health care record for an individual that incorporates data from all sources Electronic health record (EHR)
The use of financial incentives to improve the quality and efficiency of health care services Pay for performance
Medical care that is based on the latest and most accurate clinical research in making decisions about the care of patients Evidence-based medicine
A nationwide interconnected computer network that facilitates the secure exchange of health care information Nationwide Health Information Network (NHIN)
A computerized record of the physician’s encounters with a patient over time, including medical history, diagnosis, treatment, and prognosis Electronic medical record (EMR)
A comprehensive record of health information that is created and maintained by an individual over time Personal health record (PHR)
Treatment provided in an inpatient setting, such as a hospital, for urgent problems that cannot be handled in another setting Acute care
Which of the following is NOT part of the 8 core functions of an electronic health record? Pharmaceutical support
The following are advantages of electronic health records when compared with paper records, EXCEPT; Limitless access for non-health care personnel
Electronic health records are NOT in widespread use today due to the following reasons, EXCEPT; Too many standards
Two-thirds of all errors in treatment and diagnosis occur due to the following communication problems, EXCEPT; Pertinent information in medical records
Ambulatory care refers to treatment that is provided in which of the following locations Clinic
The incremental conversion approach to converting paper records to an EHR risks converting unnecessary data. T or F False
The total conversion approach to converting paper records to an EHR risks converting unnecessary data. T or F True
Clinical templates are structured progress notes that physicians use to document patient encounters in an EHR. T or F True
A personal digital assistant is a type of workstation. T or F False
A personal digital assistant is a type of handheld PC. T or F True
A client is a powerful computer that houses software applications and data. T or F False
Wireless networks, also known as “Wi-Fi,” allow multiple computers to access a server or the Internet with the use of cables. T or F False
The term network refers to all the equipment required to enable computer and other types of hardware to exchange information electronically. T or F True
In an ASP environment, the practice is responsible for hardware and software maintenance. T or F False
Tablet computers are similar to PDAs, but can also function as cell phones. T or F False
Outsourcing is the process of an organization contracting with an outside company for completion of all or part of a job. T or F True
Transcription is a method of capturing electronic text or images from paper documents. T or F False
Some EHRs offer patients the option of making appointments on a website. T or F True
With electronic check-in, the EHR verifies insurance eligibility without the assistance of the staff at the front desk. T or F True
After the patient is escorted to the exam room, the medical assistant checks the patient’s vital signs, gathers information relevant to the current visit, and enters this information in the EHR while the exam is taking place. T or F True
The electronic entering and tracking of a laboratory and radiology tests eliminates the need to pull a patient chart, file the result, and route the chart to the physician. T or F True
With computer-assisted coding, a coder must still review documentation and finalize procedure and diagnosis codes. T or F True
Disease management is a method of screening to determine which patients are at-risk for a certain disease. T or F True
A formulary’s main function is to check for interaction between the patient’s current medication and the newly prescribed medication. T or F False
A formulary’s main function is to list all pharmaceutical products and dosages deemed by a health care organization to be the best, most economical treatments for a condition or disease. T or F True
Clinical guideless are based on scientific evidence. T or F True
Templates enable providers to document patient encounters more efficiently. T or F True
The history of present illness (HPI) is an inventory of body systems in which the patient reports any symptoms experienced. T or F False
The following are conversion strategies, when considering the transition of paper records to an electronic health record, EXCEPT a. Fractional conversion b. Total conversion c. Hybrid conversion d. Incremental conversion Fractional conversion
The following are disadvantages of total conversion, EXCEPT a. Cost b. Not all patient data are available in the EHR at once c. Higher error rate because of lack of in-house oversight d. Conversion of unnecessary data Not all patient data are available in the EHR at once
On a wired network, all the client computers are connected with physical wiring called Ethernet cable
An advantage of a locally hosted system? The practice maintains direct control of the system
In order for different systems to be able to exchange information and use the information in a meaningful way they must be Interoperable
The following are types of clinical vocabularies, EXCEPT a. SNOMED-CT b. LOINC c. ICD-9 d. UMLS ICD-9
The following are examples of classification systems, EXCEPT a. ICD-9 b. LOINC c. CPT d. HCPCS LOINC
International Classification of Diseases, Ninth Revision (ICD-9) is a standard developed by: WHO
Is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers in outpatient settings CPT
Which of the following classification systems was developed and is currently maintained by the American Medical Association? CPT
Contains codes for products, supplies, and certain services not included in CPT HCPCS
Makes it possible to transfer data from systems such as laboratory or pharmacy systems to an electronic health record system Messaging standards
The following are messaging standards, EXCEPT a. HL7 b. IEEE1073 c. HCPCS d. DICOM HCPCS
A standard that enables the exchange of information between imaging systems and allow access to the images for remote locations, such as a physician office DICOM
A method of entering information in which providers dictate using a microphone connected to a desktop or laptop computer equipped with special voice recognition software, and the recording is converted into an electronic text file Voice recognition
There are only two (2) ways to exit the Medcin Student Edition software. T or F False
At the top of the screen, the words "Select, Enter, Options, Forms, Summary, Graph, and Help" are part of the "Toolbar". T or F False
The purpose of the Toolbar is to allow quick access to commonly used functions. T or F True
The middle portion of the screen is divided into two window panes. The left pane is called the Encounter View Pane. T or F False
At the top of the Nomenclature Pane, there are 5 tabs. T or F False
When creating a new encounter, the very first step to take is click on "New Encounter" under the Select Menu on the Menu Bar. T or F False
When recording a subjective finding, make sure that you have the "HX" tab in the left pane selected. T or F False
The section labled "Entry Details" is located at the top of your screen. T or F False
All of the fields in the Entry Details section apply to a single finding, the one currently selected or highlighted. T or F True
Ideally, the less free text used in the EHR, the better. T or F True
When recording objective findings, make sure that you first select the "SX" tab in the Nomenclature pane. T or F False
Under the Entry Details Section, the first item in each drop-down list is a blank. True
When recording the assessment, make sure that you first select the "PX" tab in the Nomenclature pane False
When recording the Treatment Plan and Physician Orders, make sure that you first select the "RX" tab in the Nomenclature pane. T or F True
SX Symptoms
HX History
PX Physical Examination
TX Tests
DX Diagnosis, syndromes, and conditions
RX Therapy
Selecting patients, encounters, adding chief complaint, notes, and selecting forms open small windows that close when the user is finished. T or F True
When documenting vital signs you need to locate and click on the button labeled "Lists" in the top row of the Toolbar. T or F False
Once a patient is selected the Encounter View Pane should be populated and read: Students Name, Patients Name, Sex, DOB and the Encounter Date & Time. True
The red button under the Nomenclature Pane generally means normal or not present. T or F False
The delete button is located in the Toolbar at the top of the screen. T or F False
Forms are templates that display a desired group of findings in a consistent position every time. True
Forms enable quick entry of positive and negative findings, as well as Entry Details field data such as value or results. T or F True
Forms are dynamic. T or F False
Lists arrange findings in the appropriate tab (Sx, Hx, Px, Tx, Dx, and Rx), but this means that clinicians must change tabs as they work through the encounter. T or F True
In order to display the Forms Manage winder, click on the List button in the Toolbar at the top of the screen. T or F False
Clicking on the Listsize button increase or decreases the number of findings in the displayed list. T or F True
The Auto Negative (Neg) button will automatically click set all the findings (that are not already set) to "positive" when you are on the Sx or Px tab. T or F False
Lists allow the clinician or medical practice to create a subset of the nomenclature typically used for a particular condition or type of exam. T or F True
When the ROS button is clicked to the "ON" position, histroy findings are recorded in the History of Present Illness section. T or F False
The Prompt feature provides a quick way for the provider to locate a desired finding in the nomenclature. T or F False
The Search feature generates a list of findings that are clinically related to the finding currently highlighted. T or F False
The Rx button order a test. T or F False
Orders are an essential component of any patient chart. T or F True
Nurses and medical assistants sometimes enter verbal orders into an EHR on behalf of the ordering clinician. T or F True
The use of CPOE, in conjunction with an EHR, also improves clinician productivity. T or F True
Family History - Lists past history items recorded in the EHR during all previous encounters. T or F False
Medications - Lists the patient's immunizations that have been administered at the clinic. T or F False
Clicking the Cite button brings a finding form a previous encounter note into the current encounter. T or F True
To invoke the Medcin Graph Window, click on the Summary tab in the Menu bar. T or F False
Problem lists provide an up-to-date list of the diagnoses and conditions that affect that particular patient's care. T or F True
Created by: CUAHIT