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NHAII
CEHRS
| Question | Answer |
|---|---|
| example of a technial safeguard | technical safeguard is authentication controls on a computer.(passwords) |
| whatEHR specialist use to identify the procedure | cpt codes |
| what is the following procedures shoudl the EHR specialist indicate involves regularly reviewing records, access reports, and security incident tracking reports | information system activity review (regular reviews) |
| what information should the patient enter into the EHR prior to arrival for the visit with the provider? | Recent surgery and reason for the visit |
| which of the following steps is the EHR specialist completing; verifying if a laboratory test the provider orders is covered under contract? | Precertification |
| what actions should the PTs take to autherize a parcipitating healthcare organization to recive from third party payer | a signature |
| what is one of the most important things about ICD-10-CM | ICD-10-CM codes need to be very specific |
| where can you find Cancer screenings? | in the preventative care screen |
| a provider askes how to correct the deficiencies in reporting ; what should you say | "using a template for your documentation will allow the system to produce a report that indicates required fields to complete" |
| which of the following actions should the facility take to insure security compliance and protect EHR from unauthorized access? | Issue unique user identifications for use of computers |
| what form is used to capture diagnoses and charges | Encounter form |
| how do you provide data on vaccinations to the public health agencies? | data must be anonymous and confidential |
| what is coded data? | standardized coded data can be instantly found and matched regardless of the providers choice of words |
| what is the method of notification in the EHR software? | an automatic alert message |
| enter into a business associates control with IT contractors | HIPAA secruity rule, must have a written agreement ensuring the security |
| preparing to obtain information about the pt's outcome by individual for quality improvments. | Generate and electronic clinical report using th ePT;s records |
| what is a benifit to the encoder program? | helps navigate the coding pathways |
| how does the image order show in the encouter note? | it is automatically documented in the note |
| security management process is preformed first? | Risk analysis, then risk management then sanction policy, then infomation system activity is last because it is an ongoing process. |
| how do you find pts most recent weight | physical exam section is for documetation of pts height, wieght ,blood pressure, temp, pulse, and respirations |
| What is a Remittance advice (RA) | document send to providers office and gives details of third party payer |
| technical safeguards | cover automated processes of data |
| what is a flow sheet? | used to record a patients vital signs over time |
| what is concurrent coding? | function allows coders to see documentation while the patient is still receiving treatment |
| ICD codes are considered structure data? | yes, they are stored in a specific fashion |
| When is numerical data is FIELDED AND CODED? | a unique code is assigned to each lab component so id can be located and organized sequentially to is then easily placed on a graph as a visual representation of a trend over time |
| Free Text box allows the user to do? | add note and comments to the form to enhance details of a finding |
| Health level 7 HL7 | standard and protocol used for transmitting both clinical and admin data |
| why is Determining the type of appointments important? | overlapping schedules |
| what Information should only be released with a specific patient authorization? | (HIPAA;NPP) |
| Protocols notify the provider of therapies that are indicated for a patients documents diagnosis | based on standards |
| Technical safeguards | protect and control access to PHI. This safeguard and audit controls. |
| patient aging report shows? | how long PTS have owed money to the practice |
| Clinical quality measures reporting is? | obtained directly from information into the EHR. CQMs include patient health outcome. |
| Reportable lab results are required to be submitted to Public health agencies | Measles, rubella, and anthrax are all reportable examples |
| Text data files | would provide a current narrative note |
| PHI in the office? Technical safeguards ? | Provided each PT with a number at check-in |
| The lab work request contains | a pts name diagnosis and other identifying demographics |
| VPN | "Transmissions to all devices used by our staff take place over virtual private network" |
| The uniform ambulatory care data set; | data set is used for for registration in a providers office or out patient clinics |
| Medical Service order from the employer authorizes the health care organization to treat and injured employee | it should be photocopied and scanned into the pts record |
| User permission define the areas of the EHR that can be accessed based on the users duties.(what are access controls) | this helps ensure security and confidentially of medical records by limiting unnecessary access to information. |
| which of the following fields is required when developing a template for authorization? | to whom the information can be disclosed |
| which of the following is accessible in the patient education area of the patient portal? | information from the American cancer society |
| when assisting with training you should tell them what about e-prescribing? | "a renewal authorization an be transmitted using this feature" |
| EHR specialist should to prevent from an past medical coder cannot access the system? | terminate the account |
| which of the following HIPAA standards monitor control for accessing the neighbors PHI without reason for treatment? | Technical safeguards; protect and control access to PHI. includes access and audit controls |
| the provider has not encountered this diagnoses for several years which would help in determining the current treatment? | CDSS/clinical decision support system |
| which of the following will mitigate security threats such as a data breech? | physical safeguards; protect electronic systems and resitricting access to PHI. |
| which of the following data must be de-identified? | lab work request documentation must be de-identified when it is not being used for treatment. |
| statement that shows their appointments and detailed charges? | Itemized statement |
| what should the coder to do to ensure automated information regarding diagnosis code is accurate for Medicare reimbursement? | Validate whether the coded diagnoses were present on admission(Electronic Medical Record) |
| labs can generate a visual representation of trends in a patient lab result over time? | Field and coded data; when numeric data is field and coded, a unique code is assigned to each lab, it is then easily places on a graph as a visual representation . |
| what information should be included in the H&P section? | Benin colon polyps |
| what type of type data would go on a template for a heart transplant? | coded data; easily searched and specific for reporting purposes. |
| CDSS presents the provider with standard plans of therapy for documented diagnoses | protocol; notify the therapies that are based on stablished standards. |
| how do you generate a report with fields including claims that need to be billed by the patient? | billing/ payment status report |
| CQM's | Clinical Quality Measure/PT's outcomes |
| what is a medical service order? | authorizes the health care organization to treat an injured employee. |
| Internal data is | recorded by PROVIDERS (and sometimes the patient) during an encounter |
| External data | digital images, laboratory results often starts OUTSIDE of the office where the patient record lives. |
| Verify PTs identifiers before documenting in the EHR to ensure information is recorded in the correct chart. | medical record number (MRN). |
| Retrieve PTS information from internal databases (e.g. Provider database/ financial Database) to integrate into the PTS information. | Scanned documents are labeled and coded with information that enables users to locate them in the system. |
| Acquire PTS data from external sources ( e.g., Diagnostic laboratories, ancillary facilities, other health EHR system | integrate paper documents into EHR systems by scanning them as images, which are uploaded into the patient’s EHR/Patient kiosks allow patients to sign into the waiting room using a computer. |
| Provide initial ongoing end-user training of the EHR software to maintain competency (e.g. for new hires, upgrades and deployments.) | staff members understand the system and promote usability. |
| usability. | The ease with which a person can interact with hardware and software to provide safe, efficient, quality patient care. |
| TRAINING AND UPDATES | Staff must continue on going training with EHR software training and safe delivery of quality care by increasing efficiency and securing recorded data in the system. |
| Locate and provide patient education materials available within the EHR. | education materials are available in the patient portal, or Plan of Care within the EHR. |
| Develop clinical templates for data capture (e.g. by diagnosis, by procedure, by practice) | |
| securely transmit and exchange PTs data internally and externally( e.g. pharmacy | |
| process of capturing data | starting the (CATALOGING) process of (data capture) by asking patients to enter information about their medical, family, and social history, current medications, symptoms, and CC |
Created by:
ellegoddess2305