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WGU BDV1 Module 5

WGU BDV1 Mod 5 Health Data Management across the continuum (AHIMA C2V3)

Name one limitation of a traditional paper based health record? View of the information cannot be customized to the needs of the user.
Documents in a health record are grouped according to their point of origin. Source-oriented Health Records
Documents in a health record are arranged by the patients past and present social, psychological, and medical problems. Problem-oriented Health Records
Which health record format best serves the needs of the patient and end user of the record? Problem-oriented Health Records
Documents in a health record from various sources are intermingled and follows strict chronological order? Integrated Health Records
Which health record is easiest to follow the course of the patients diagnosis and treatment? Integrated Health Records
Which health record makes it most difficult to compare similar information? Integrated Health Records
What is the ultimate goal of every health record? To facilitate communication
Name a disadvantage of a paper-based health record? Can only be viewed by one user at a time
Name a disadvantage of a paper-based health record? Updating may be difficult due to the location of the chart
Name a disadvantage of a paper-based health record? Records are subject to damage or being misplaced or misfiled
Database model used by some EHR's to maintain the information in a department based computer system or subsystem. Distributed Model
Name an advantage that an EHR may have over a paper-based health record? Ability to include image files along with other reports and documents
Name an advantage that an EHR may have over a paper-based health record? Text search and retrieval
The following represent what type of technology in the EHR? (Voice Recognition, OCR, Bar Code Readers, Document Imaging, Automated Templates, Structured Data Entry) Data Input Technologies
What are the following EHR considerations? (Presentation of data, Need to know, Quick Search capabilities, and Analytical) Capabilities) Data Retrieval Design
What are the following organizations working to achieve in the healthcare industry? (HL7, ASTM, IEEE, ACR/NEMA, ISO, SNOMED, NLM, UMLS) IS Standards for data exchange and vocabulary
This challenge to EHR Systems includes a lack of a common data model, common set of data elements, common vocabulary, common structure? Lack of clear definition
This challenge to EHR Systems includes being all things to all end users? Difficulty in meeting the needs of multiple end users
The lack of standardization for EHR Systems was addressed by this private organization in 2005 with the adoption of HL7 as a starting point for EHR certification. Certification Commission for Healthcare Information Technology
This challenge to EHR Systems includes finding a balance between access and restrictions. Potential threat to privacy and security
This challenge to EHR Systems includes uncertainty of the cost-to-benefit ratio of installing systems. Development and implementation cost
This challenge to EHR Systems includes development of a timeline and tolerance to accept the EHR technology. Organizational and Behavioral Resistance
This allows a facility to thoroughly investigate the needs of it's users and gradually address the weaknesses and challenges of an EHR. Hybrid Health Record
Includes both paper and electronic records as well as manual and electronic processes. Hybrid Health Record
True or False. The CPR functions in part as a decision-making support tool. The EMR lacks this functionality. True
Which is NOT an obvious goal of the electronic record? (Improve patient care, reduce medical errors, increase operational effeciency, manage productivity, reduce costs) manage productivity
CPR Computer-based patient record
CDR Clinical Data Respository
The CDR was thought to support concurrent and retrospective ____________. decision making
The CDR was expected to serve as the _____________. longitudinal record
Early studies indicated that CPR's were basically on implemented in this type of facility. inpatient
There were few instances where the CPR was exchanging health informatin seamlessly with __________. quality reporting agencies
Which type of electonic record did not generally include scanned documents? CPR
Which type of electonic record introduced scanned documents as well as dictation and transcription? EMR
It was clear that the CDR could not support ________. retrospective decision making
What type of electronic health record proved to be less expensive and provided clinicians with the option to review then entire record, but did not support data extraction and reporting? document imaging
Which electrnic health record was expanded to various settings of care across the enterprise, but failed to exchange information with phy offices and provide seamless reporting to publich health, regulatory, or accreditation agencies? EMR
Early electronic health records tended to focus on these essential features. alerts, med administration, order communication
This type of health record introduced fully integrated evidence-based medicine; seamless health information exchange between providers; reporting diagnoses as a near real-time transaction; and embedded clinical terminology to assist with documentation. EHR
This type of health record puts a clear emphasis on data with the ability to exchange informaiton across a network, and to facilitate quantitative analysis (outcome studies, population health). EHR
This type of health record focuses on a longitudnal record that spans the various providers and settings of care over a lifetime. EHR
This type of health record is expected to proliferate beyone the inpatient and ambulatory settings of care. EHR
This type of health record has an draft standard developed by Health Level 7? EHR
Which type of health record is certified by the national coordinator for healthcare information technology? EHR
Besides coding based on provider documentation by an HIM coder, what other method of coding is possible? Provider assigned coding
Manufactured documentation for the express purpose of supporting a higher level code than the actual service warranted is one method of generating this. False claim
The role of the coding professional is to translate ____________ into the appropriate codes according to the conventions and guidelines that apply to that particular coding system Clinical information
Clinical codes are also assigned by a computer program called a _____________ for ancillary services where there is no need for interpretation of actual clinical data for code selection. Chargemaster or Charge Description Master (CDM)
Name step 1 of the Coder Method. Case Assessment
Name step 2 of the Coder Method. Overview of Key Reports
Name step 3 of the Coder Method. Data from Clinical Reports
Name step 4 of the Coder Method. Evaluations and Exclusion
Name step 5 of the Coder Method. Reviews, Refinement and Reimbursement Impact
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