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EHR week/1
Week/1 EHR assignment questions.
| Question | Answer |
|---|---|
| When thinking of an Electronic Health Record (EHR), the word audit means what? | A review of employee activity within the EHR system. |
| An EHR function that allows a doctor or other prescriber to order medication and test using an automated format is called? | Computerized Physician Order Entry (CPOE) |
| The ability of separate EHR systems to share information in compatible formats is called? | Interoperability |
| If both parents cover dependents on their plan, the child's primary insurance is usually determined by the birthday rule. What is meant by the birthday rule? | The parent whose birthday is earlier in the calendar year is primary. |
| An active patient is defined as? | One who saw the provider within the last 3 years. |
| Which code indicates the type of visit? | TOV code |
| When you electronically archive patient records, where do they go? | To archive media such as a CD or a hard drive. |
| Why should closed patient records be purged and placed in electronic storage? | Liability reasons in the event a medical malpractice. |
| What is the purpose of a billing audit? | To identify poor coding. |
| Lack of documentation during a patient visit could result in? | Decreased reimbursement |
| A reference database of medical vocabularies is called? | UMLS |
| Claire works for a pediatrician's office that is considering the implementation of an EHR. She has been asked to research the different systems available and to create a list of functions the EHR should have specific to this company. She should start by asking for? | Doctor Recommendations |
| If a patient has had a malignancy removed and no further treatment is needed, it is coded as? | History |
| The best definition for a company that processes health information and executes electronic transactions is a? | Clearinghouse |
| Which of the following terms is unique to ICD-10-CM and indicates that the condition being excluded is not part of the condition under which is being listed but rather another code should also be assigned? | Excludes |
| How is payment received in an electronic office? | An electronic deposit is made into an online office account; so money can then be transferred as needed. |
| Evaluation and Management Codes (E/M Codes) are based on three factors: history, physical examination and? | Evidence of Medical Decision making. |
| The process of moving a patient from appointment making through checkout is called? | Patient flow |
| According to the flow of information what comes next: appointment scheduling, front desk/check in, nursing staff and? | Care provider |
| What is easily attained when using an EHR system? | Interoperability |
| Data may be structured or unstructured. Identify an example of unstructured data? | Dictated report |
| What type of software is available to physicians in order to access current information about a disease or condition? | Decision Support Software |
| Administrative data is not necessary for? | the care provider. |
| Health Level 7 (HL7) standards allow? | different software to interface with each other. |
| Using a _______ _____________ will ensure each member of the staff has defined the data element correctly. | data dictionary |
| Computerized records of (one physician's) encounter with a patient over time and reflects treatment of that one physician. | Electronic Medical Record (EMR) |
| Reflects data from (all sources) that have treated an individual? | Electronic Health Record (EHR) |
| Registration, Admissions, Discharge and Transfer acronym? | RADT |
| A unique patient identifier that links all clinical observations, tests, procedures, complaints, evaluations, and diagnoses to the patient? | UPI |
| A dictated report, a written progress note, or voice files are what kind of data? | Unstructured data |
| Standard templates, bar codes and numeric codes are what kind of data? | Structured data |
| The length of time records are stored by a medical office is called? | Retention Time |
| Indicates a patient's behavior or current status? | Status Code |
| Codes that identify common types of patient visits, specify their typical duration and identify special instructions to handling each kind of visit? | Type of Visit Code |
| Rules that require the usage of password protection on all electronic devices used to access patient information? | HIPAA Security Rules |
| Identifiers are a unique set of numbers (like SSN's) used in electronic transactions, for Employers, Healthcare Providers, Health Plans and Patients and are called? | HIPAA national Identifiers |
Created by:
Healthtrade