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Mod C Unit 4
Review
| Question | Answer |
|---|---|
| The advantages of the electronic health record include ______,_____, and ______ | Security, multiple users, and decision support |
| The electronic medical record differs from the paper-based record by including what functions? ______ and _____ | alert, reminders |
| Legislation which makes it a criminal offense to accept bribes or payment for services rendered (this includes money, gifts, gratuities or discounts) is called the ______ | Anti-Kickback statute |
| What software applications commonly interface with the electronic health record_______ | transcription |
| Health care organizations, administrators and clinicians want to be assured that the EHR will improve the quality of _____ | care |
| The ____ published two major reports that outlined the functionality of the computerized patient record | Institute of Medicine |
| A drug interaction alert would be a typical function of a ___ decision support system. | Clinical |
| An industry standard that explains what should, shall, and must be included in the electronic health record is called a ______ standard | functional model |
| One of the major challenges in developing a computer-based patient record is _______ | interoperability |
| A disadvantage of the EHRs__________ and ________. | cost, training |
| Federal mandates to protect patient information are incorporated into the ________. | HIPAA |
| The most common type of health information is ________. | clinical data |
| Transaction standards for electronic data interchange in health care have been developed by ________. | HL-7 |
| ________ is defined as intentional acts, deception or misrepresentation of billing information to gain insurance benefits | Fraud |
| Under the Security Rule, physician practices that transmit electronic data must provide ______________. | Cyber Space Insurance |
| The security rule only covers _______________ while privacy covers ___________, ___________, and ________. | electronic PHI, oral, written and electronic |
| HIPAA established national standards that address _______, ______, and _________. | privacy, confidentially and security |
| What type of record is considered the bridge to the EHR? This type of record is stored on both paper and electronic media. | hybrid |
| When a medical assistant request the record of a patient for whom he or she did not provide care or treatment, the medical assistant had violated HIPAA's _________ principle. | Need to Know |
| Tracking of an appointment is considered a(n) ________ use of the EHR. | administrative |
| ________ is best demonstrated when data elements and information are collected by one system and shared with another. | Accessing |
| SOAP notes are considered _________ data. | clinical |
| Safety requirements such as fire alarms, extinguishers, smoke detectors and equipment are referred to as _______ safeguards. | Physical |
| Whistle-blower protections are known as _____________. | Qui-Tam Statute |
| __________ is the process of identifying the author? | Authentication |
| The acronym used in the HIPAA Security Rule for protected health information in the electronic format ________. | EPHI |
| _________ is the practice of securing data by changing the original message in the text so it is unreadable - it is used to protect data when transmitting information electronically. | encryption |
| Data elements such as temperature, pulse and respiration would be charted as ________ data. | clinical |
| What tool provided the caregiver with clinical information that can be used for gathering data and information for a variety of computer systems _________ support. | decision |
| Demographic, medical record number, physician name and address are examples of __________ data. | administrative |
| A principle of the HIPAA Privacy Rule that allows access to protected health information based on the user's role or job requirements is called ____________. | Need to Know |
| Authentication controls, encrypting and decrypting data are examples of _________ safeguards. | technical |
| __________ is standard that provides a means to exchange (communicate) patient information. | Messaging |
| What accurately describes a covered entity _______ provider. | healthcare |
| The traditional method is used in the collection and storage of medical information is the ________ format. | paper |
| A health care clearinghouse company performs what type of function? __________ | billing |
| Improper or harmful conduct by a health care business (e.g., insurance, medical office) in its fiscal or ethical practices is called ________. | abuse |
| ___________ provided standards for the electronic protected health information. | Security Rule |
| The electronics health record usually contains a system whereby the physician can order medications. this order can be directly linked to an insurance formulary and the patient's pharmacy. It is called __________________. | computerized physicians order entry |
| The ______ is a system that provided patient data, alerts, reminders, and clinical decision support systems that link to medical knowledge. | EHR |
| The term _______ is used in the electronic health record to provide a warning or a reminder to clinicians. An example of this is when a physician receives an automatic message of an reminder of immunizations for his or her patient. | alert |
| A wireless device that allows the clinician to enter or input data at the point of care such as a pocket-sized computer used for appointments, notes, and other information is commonly referred to as a ________. | PDA |
| The process of charting a patient's information using drop down screens in the electronic health record facilitate fast and easy capturing of ______________ data. | Structurally Uniform |
| An individual's right to control his or her personal health information, with the understandings that the information will not be disseminated without his or her permission is called _______. | Privacy |
| _____________ is defined as the ability of systems to work together through common standards. | Interoperability |
| ____________ is a federal law that prohibits fraudulent claims to the government. | False Claims Act |
| _________ is a standardized form that has a predesigned format and a limited selection of choices. | Template |
| Keeping information private whereby only authorized individuals have access to medical information is called ________. | confidentiality |
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