WGU BDV1 Mod 5 Health Data Management across the continuum (AHIMA C2V3)
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| Name one limitation of a traditional paper based health record? | View of the information cannot be customized to the needs of the user.
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| Documents in a health record are grouped according to their point of origin. | Source-oriented Health Records
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| Documents in a health record are arranged by the patients past and present social, psychological, and medical problems. | Problem-oriented Health Records
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| Which health record format best serves the needs of the patient and end user of the record? | Problem-oriented Health Records
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| Documents in a health record from various sources are intermingled and follows strict chronological order? | Integrated Health Records
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| Which health record is easiest to follow the course of the patients diagnosis and treatment? | Integrated Health Records
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| Which health record makes it most difficult to compare similar information? | Integrated Health Records
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| What is the ultimate goal of every health record? | To facilitate communication
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| Name a disadvantage of a paper-based health record? | Can only be viewed by one user at a time
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| Name a disadvantage of a paper-based health record? | Updating may be difficult due to the location of the chart
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| Name a disadvantage of a paper-based health record? | Records are subject to damage or being misplaced or misfiled
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| Database model used by some EHR's to maintain the information in a department based computer system or subsystem. | Distributed Model
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| 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
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| Name an advantage that an EHR may have over a paper-based health record? | Text search and retrieval
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| 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
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| What are the following EHR considerations? (Presentation of data, Need to know, Quick Search capabilities, and Analytical) Capabilities) | Data Retrieval Design
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| 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
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| 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
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| This challenge to EHR Systems includes being all things to all end users? | Difficulty in meeting the needs of multiple end users
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| 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
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| This challenge to EHR Systems includes finding a balance between access and restrictions. | Potential threat to privacy and security
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| This challenge to EHR Systems includes uncertainty of the cost-to-benefit ratio of installing systems. | Development and implementation cost
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| This challenge to EHR Systems includes development of a timeline and tolerance to accept the EHR technology. | Organizational and Behavioral Resistance
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| 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
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| Includes both paper and electronic records as well as manual and electronic processes. | Hybrid Health Record
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| True or False. The CPR functions in part as a decision-making support tool. The EMR lacks this functionality. | True
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| 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
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| CPR | Computer-based patient record
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| CDR | Clinical Data Respository
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| The CDR was thought to support concurrent and retrospective ____________. | decision making
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| The CDR was expected to serve as the _____________. | longitudinal record
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| Early studies indicated that CPR's were basically on implemented in this type of facility. | inpatient
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| There were few instances where the CPR was exchanging health informatin seamlessly with __________. | quality reporting agencies
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| Which type of electonic record did not generally include scanned documents? | CPR
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| Which type of electonic record introduced scanned documents as well as dictation and transcription? | EMR
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| It was clear that the CDR could not support ________. | retrospective decision making
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| 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
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| 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
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| Early electronic health records tended to focus on these essential features. | alerts, med administration, order communication
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| 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
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| 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
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| This type of health record focuses on a longitudnal record that spans the various providers and settings of care over a lifetime. | EHR
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| This type of health record is expected to proliferate beyone the inpatient and ambulatory settings of care. | EHR
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| This type of health record has an draft standard developed by Health Level 7? | EHR
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| Which type of health record is certified by the national coordinator for healthcare information technology? | EHR
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| Besides coding based on provider documentation by an HIM coder, what other method of coding is possible? | Provider assigned coding
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| 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
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| 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
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| 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)
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| Name step 1 of the Coder Method. | Case Assessment
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| Name step 2 of the Coder Method. | Overview of Key Reports
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| Name step 3 of the Coder Method. | Data from Clinical Reports
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| Name step 4 of the Coder Method. | Evaluations and Exclusion
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| Name step 5 of the Coder Method. | Reviews, Refinement and Reimbursement Impact
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