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a drug or substance regulated by the government controlled substance
used to measure blood pressure. vitals cuff
department of a hospital cares for patients who have cancer oncology
All software that contains e-PHI must have a___ or ___ to report who has viewed a patient’s information tracking, auditing system
Schedule _____ of controlled substances is described as “high potential for abuse, may lead to severe psychological or physical dependence.” II
Cough preparations containing less than 200 milligrams of codeine per 100 milliliters or grams fall into Schedule _____. III
Trauma level ________ means the center provides initial evaluation, stabilization, and diagnostic services. Patients are transferred to a higher level of care facility when needed. If not open all hours, the trauma center must have an after-hours response V
_______ is an imaging process that shows soft tissue using high-frequency sound waves and echoes Ultrasound
________ is an imaging process that creates an image of the body or function of an organ using a radioactive tracer. Positron emission tomography (PET)
A(n) ____________ is a test that measures the frequency of brain waves. Electroencephalogram
______ is a coding system maintained by the American Medical Association to represent procedures or treatments offered by healthcare providers Current procedural terminology
Which of these is an information system designed to store and retrieve different formats of medical imaging in one location, as well as communicate with other information systems? Picture archiving and communication system
Which of these is a widely used file format developed by Adobe Systems used to present digital documents in a printable view on a monitor? Portable document format
Which of these translates printed lettering into pure text that can be searched and manipulated on a computer? Optical character recognition (OCR)
A(n) _________ is a version of a patient’s record for transferring relevant data? Continuity of care document
A(n) ___________ is the interface pipeline that connects two information systems Thread
The HL7 segment with order information that contains observation request is ______. OBR
A(n) _______ is a connection point to an IS. Node
Which of the following centralizes all medical images for search and retrival? DICOM
Image file format that supports data compression and animation Graphics interchange format
Healthcare industry standard for medical digital imaging, designed specifically for image handling, storing, printing, or transmitting Digital imaging and communication in medicine
File format developed by Adobe Systems used to present digital documents in a printable view on a monitor Portable document format (PDF)
Medical terminology standard used internationally to create consistency in keywords in medical documentation Systemized nomenclature of medicine – clinic terms
Data about data Metadata
Schedule I No accepted medical use
HL7 segment for insurance information IN1
Translates printed lettering into pure text that can be searched and manipulated on a computer Optical character recognition (OCR)
Stores and retrieves different formats of medical imaging in one location Picture archiving and communication system
Device used to measure blood pressure Vitals cuff
Term used in healthcare to express urgency Stat
Primary care physician (PCP) Ongoing relationship with patient
Required to have a residency program Level I trauma center
Immediate intervention Code blue
Between critical care unit and general nursing unit Stepdown
Transmitted to pharmacy e-prescribing
We all looked at that celebrities record Audit trail
Unstructured documentation Free text
Change management (CAB) change advisory board
Imaging without radiation or injection Ultrasound
Used primarily for encoding diagnoses and the resultant billing. (ICD-10)
ICD-10 International Classification of Diseases, Tenth Edition
CPT Current Procedural Terminology
a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT
a systematic, computer-processable collection of medical terms SNOMED-CT
SNOMED-CT Systematized Nomenclature of Medicine
Common Physicians Roles in a Hospital Admitting, Attending, Consulting
List some places in a large hospital that would have their own scheduling software – integrated of course into the HIS Housekeeping, Surgery, Lab, Imaging
the collection of patient information from all visits at one hospital EMR
collection of patient information from all hospitals the patient has visited. EHR
the level of care that a patient requires Patient acuity
a mobile X-ray machine that is small enough to be rolled to a patient’s room. portable X-ray machine
an image taken of soft tissue using high-frequency sound waves and echoes ultrasound
imaging that uses X-rays along with computing algorithms computed tomography (CT)
CT computed tomography
MRI Magnetic resonance imaging (MRI)
imaging that uses strong magnetic fields and radio signals to create an image of a patient’s body. Magnetic resonance imaging (MRI)
PET positron emission tomography
imaging that creates an image of the body or function of an organ using a CT scan with a radioactive tracer positron emission tomography (PET)
measures blood glucose levels glucose monitor
measures the frequency of brain waves electroencephalogram (EEG)
EEG electroencephalogram (EEG)
tests for problems with the electrical activity of the heart electrocardiogram (EKG or ECG)
determines the capability of veins to return blood from the lower limbs to the heart. vascular stress test
used to diagnose and treat some heart disorders nuclear stress test
test combines two PET scans before and after a vascular stress test. nuclear stress test
A doctor uses a_____ to enter orders for a patient. computerized physician order entry (CPOE)
used in several different departments of a hospital to schedule services offered Scheduling software
used to follow and record patient flow through a patient’s changing medical status, lab studies, imaging, or other diagnostic and treatment services Patient tracking software
software tracks the physical location of a patient in a hospital using radio frequency radio frequency identification (RFID) technology
RFID radio frequency identification (RFID) technology
software facilitates the creation, duplication, and safety of orders given by healthcare providers. Order entry (OE)
OE Order entry
software to electronically write a prescription for a patient e-prescribing
an all-encompassing software solution to manage both clinical and business needs in a small- to medium-sized medical office, such as a physician’s practice or an outpatient medical office. Practice management software
receives data from a patient’s EHR or EMR, converts the data into billable items, and submits the bill to the insurance company for reimbursement Billing and coding software
codes describe diagnosis or classification of diseases or illnesses ICD-10
the standard in the medical field for saving digital images. Digital imaging and communication in medicine (DICOM)
DICOM Digital imaging and communication in medicine
centralizes all the different types of medical images into one information system, stores and retrieves medical images, and communicates medical images with other information systems. Picture archiving and communication system (PACS)
PACS Picture archiving and communication system
program scans an image and translates the text from the image into pure text that is searchable. optical character recognition (OCR)
data about the data that acts like tags containing keywords, such as a patient’s MRN, to make searching for a specific file faster and easier metadata
also called change control, is a process to define a change needed, the steps to take to complete it, the results of the change, and the timeframe for completion Change management
responsible for approving pending change management requests change advisory board (CAB), or governance board
Four IS environments used during the change management process are development, QA/test, user test, and production/live
provides an easily transferred snapshot of a patient’s record, which can be easily read by a person or by an IS continuity of care document (CCD)
CCD continuity of care document
a collection of CCDs, spanning multiple patient visits, sometimes called patient encounters continuity of care record (CCR)
CCR continuity of care record
The ______ is usually the first physician a patient sees when he experiences a new illness or medical condition and for regular checkups. PCP
A ______ is imaging that creates an image of the body or function of an organ using a _____ scan with a radioactive tracer. PET, CT
An _____ or _____ tests for problems with the electrical activity of the heart. EKG or ECG
The _____ cares for preterm babies. NICU
The _____ provides general care for adult patients in a hospital. MED/SURG
The _____ cares for patients leaving the OR as the anesthesia wears off. PACU
The ______ is a code assigned to each drug used by the FDA to maintain a list of drugs being produced. NDCID
_____ codes justify billing the _____ codes. ICD-10, CPT
______ technology translates several ways to describe the same medical term into a single code. SNOMED-CT
Every ______ message contains an ______ segment that contains information about the message type and date/time stamp. HL7, MSH
What is the difference between an EMR and an EHR? EMR is the collection of patient information from all visits at one hospital, EHR is the collection of patient information from all hospitals the patient has visited
What does a healthcare provider mean when he orders a medication to be given “stat?” medication should be given immediately
Which level trauma center is most equipped to care for a trauma patient because the facility has a full range of specialists and equipment available at all times? Level I
Why might a physician order a CT scan over an X-ray for a patient? CT machine produces an image with 100 times more clarity than normal Xray imaging
Why must all employees, including HIT personnel, be careful when entering a room with an MRI machine present? Absolutely no metal must enter the room because it can cause a dangerous situation as the magnetic field pulls the object to the machine.
What is the difference between obstetrics and gynecology (OB/GYN)? Obstetricians care for women who are pregnant, and gynecologists care forwomen at any other time
Which inpatient department cares for adolescents? Pediatrics (PEDS)
What service does occupational therapy (OT) offer? offers rehabilitation to disabled patients to restore meaningful and purposeful activities of daily living
What is the purpose of nuclear medicine? deals with the use of radioactive substances for diagnosis, treatment, and research of medical conditions
What type of information might a patient give during registration? Full name Address Employer Next of kin Billing and insurance information Referring and family physician information
How might computerized physician order entry (CPOE) be different from the order entry IS that nurses use? customized to the doctor’s needs because it has the capability to enter prescriptions
How is scheduling software specifically designed for healthcare use? offer conveniences, such as reserving rooms, procedures, and personnel based on the type of procedure or service
What are two types of patient tracking software? patient’s changing medical status, RFID)
Explain the difference between ICD-10 codes and CPT codes. ICD-10 codes justify billing the CPT codes
What services does a healthcare clearinghouse offer? collects the CPT codes and gives the codes a monetary value
What is the standard file format in the medical field for saving digital medical images? digital imaging and communication in medicine (DICOM)
What is the technology that translates printed lettering from a scanned image into pure text that can be searched and manipulated on a computer? optical character recognition (OCR)
Why is it important to consider the time of day to implement a change when creating change management documentation to be submitted to a CAB for approval? downtime, choosing off hours might be best to decrease the number of healthcare providers who will be affected
What is the difference between a continuity of care document and a continuity of care record? Many CCDs can make up a CCR.
What symbol in an HL7 segment separates fields? What does it mean when two symbols are side by side with nothing in between them? The vertical bar | separates each field. Two vertical bars together indicate the field is present, but contains no data
Created by: Wynston