NHA CEHRS FINAL EXAM 2024-2025, Exams of Nursing

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NHA CEHRS FINAL EXAM 2024-

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what does the focus of training ensure? that staff members understand the system and promote usability. what are clinical templates useful for? assisting providers and other clinical staff with charge capture, billing, and coding. how can users select common documentation elements? from checkboxes and dropdown menus. what can EHR vendors do? develop systems to meet the specific needs of an organization. the National Committee on Vital and Health Statistics Uniform Ambulatory Care Data consists of how many core elements which must be present in all ambulatory care records? 16 how many preloaded templates be in an outpatient setting? generic, or the EHR vendor may be able to customize templates for the practice. what must you do before creating your own template? check for system permissions. can you create customized templates in an INpatient environment?

OFTEN not allowed what happens during the implementation phase? consultants and technical experts from the EHR vendor should be on-site to work with every department using the system to document workflow and ensure that templates support the organization. how do many organizations start the process of data capture? by asking patients to enter info about their medical, family, and social history, current medications, symptoms, and concerns. where can reports on specific quality measures (health maintenance, preventive care screenings) be sent? to the Centers for Medicare and Medicaid Services. can patients monitor their health status or share it with providers in their patient portal? YES what is a PHI? any information held or used by a covered entity or its business associates that identifies an individual. what are examples of covered entities? Healthcare providers/organizations, health plans, healthcare clearinghouses, & insurers.

specifically: doctors, nurses, dentists, radiologists, laboratories, and pharmacies what doesn't apply to de-identified info used for marketing, staffing projections, or supply chain activities? HIPAA nor state privacy and security rules even if it is allowed under HIPAA, should a staff member still obtain written permission from a patient under the release of their PHI? YES what must all employees who view or use PHI do? sign a confidentiality agreement that ensure they are aware of their responsibility to maintain patient privacy and security. what do most inpatient documentation in the EHR consist of? nursing and provider notes. how can one assist providers to improve their documentation practices?

by using EHR-generated reports about data such as number of open notes organized by provider and frequency of remote log-ins, along with observations and interactions. what is the basis of billing and payment for health services? clinical documentation(aka charting) what do clinical encounters consist of? history, physical examination, assessment, and treatment plan. what are the medical decision-making components of an encounter note? the assessment and treatment plan. during documentation, what are the history, exam, and medical-decision making components further broken. down into? subjective elements, objective data, provider's findings/impressions, and provider's present and future plan. what can the historical info and review of systems be? a complete body systems review of focused on systems related to the chief complaint.

same with the physical examination. what does the provider synthesize the objective and subjective elements to form? an impression of the patient's status or diagnosis, which is then added to the patient's problem list. which organizations are subject to government audits? Medicare billing practices(documentation errors impact the bill to Medicare), and health care organizations what does an organization use for information on coding? a clinical documentation improvement specialist.

this profession clarifies documentation requirements on all sides. what should policies and procedures of the compliance program be? WRITTEN, everyone should learn them as their responsibilities. what should providers know? documentation guidelines pertaining to billing and coding, which are major areas where errors and fraud can take place. why must clinical documentations be finished within a specific time frame? to avoid interruptions in the revenue cycle.

what is one of the most challenging and commonly used areas of coding? E&M codes.

they are based on the level of key components documented. -some are based on other variables such as time spent or the age of the patient why and what is an important component of an E&M encounter? patient history -it is impt. for new patients, consultations, hospital admissions, and preoperative visits. what are included in the history component? chief complaint history of present illness review of systems past history family history social history what if a patient is not experiencing any of the symptoms the provider asks them in a review of systems? the provider checks a box corresponding to negative symptoms rather than clicking "normal."

the values are automatically transferred to the ROS section of the encounter note. where are past, family, and social histories frequently entered? into EHR templates and stored in a separate history section. if for example, blood glucose levels in the patient's record are stored as discrete data in the EHR, what can you do? prepare reports as needed for the provider to show blood glucose values at the time of the office visit. how do outpatient visits occur.

1. if not an emergency, the patient arrives and is greeted at the office.
2. financial and demographic info are updated.
3. patients move to the clinical area and a nurse or med assistant updates any changes to meds, history, or allergies.
4. provider reviews patient's historical data and other data gathered into the encounter note.
5. provider interviews patient, records a SOAP note.
6. physical examination is followed.
7. provider synthesizes everything together and sets a plan for further evaluation and treatment.
8. provider links any relevant patient education material to the encounter and summarizes the encounter and follow-up plan with the patient.
9. the provider signs the documentation and the patient checks out.

10. the patient receives a follow-up reminder, summary of the visit, any relevant educational materials, and instructions for assessing the patient portal. where are vital signs and measurements documented? in the vital signs flowsheet of the EHR.

they can then be viewed on graphs that follow trends in weight, bp, hr, & other data. what is the process of inpatient stays? same as OUT patient but between admission and discharge in which medical assistants, nurses, & providers gather info, it may be repeated many times. is the medical record up to date? YES, always, the most current info is accessible to all personal. what is the first step in helping an individual or organization adopt POC documentation? understanding the workflows and processes during a typical workday. -involve the clinical staff in workflow analysis -consider creating a flowchart showing each step needed to accomplish a particular task -encourage questions and comments about their individual workflow -spend time with individual members where do most difficulties encountered in POC EHR stem from? inadequate consideration of human factors. why is it not good to avoid using the designed system and looking for other ways? this is because workarounds that bypass the cumbersome workflow can also bypass associated functions critical to patient safety. when is it the ideal time to apply the principles of human factors engineering? when staff members are using workarounds. what contributes to the local success in an organization and global success for integration of EHRs into health care? Identifying workarounds and then finding system-based solutions that streamline the process what was the original intent of the creation of CPOE documentation? to reduce medication errors. what can be inputted during an inpatient stay? after a provider inputs an admission order using CPOE, they can enter: the patient's diet, meds, tests, and patient care orders(nursing notes), specify if the patient can walk, the number of dressing changes, etc.

how are results from imaging studies available through an EHR during an inpatient stay? due to interop. that allow the radiology and laboratory systems to share data with the EHR system. what happens once a CPOE order is verified? the pharmacy system can send the info back across the interface to populate the patient's record in the EHR system. can a nurse administer medication? YES, higher than that would be a nurse practioner. what is needed for an order for consultation by a specialty provider? a consultation note is automatically routed to the ordering provider so they can access the info from the consultant. how is CPOE used in an outpatient stay? the details of the prescription are transmitted to the outside pharmacy and automatically added to the patient's medication list.

the pharmacy then fills the prescription and prepares it for the patient to pick up. what happens if no further documentation are done on orders? the system can generate reports on unprocessed orders, which prompt an alert rather than allowing the care to go undone until someone remembers it. what does the systems drug utilization review program generate? alerts for the provider on potential interactions between medications that are newly prescribed and those already on the patient's medication list, as well as inappropriate dosages or potential reactions from known allergies or intolerance. what does the CPOE usually interface with? the clinical decision support system. -the CDSS also provides guidelines for imaging and tests in order to reduce unnecessary or redundant procedures. what can the systems drug utilization review produce? formulary alerts indicating whether a medication is covered by the patient's insurance and suggest equivalent alternatives. what can a patient access on their online portal? a copy of their visit note, education materials, results, etc. how can providers locate codes at the POC? from a drop down menu, and coder responsibilities in the record supports the code assignment.

what do encounter forms use? drop down menus and prepopulated lists. what does a built in software eliminate? eliminates potential communication problems. what versions are classification systems set in? electronic and a hard copy manual. when do you reference the ICD-10-CM index? first when searching for a code and review the tabular list to validate the accuracy of code assignment. how is the ICD-10-CM manual written? with specific formats and conventions that assist in coding (symbols, punctuation marks, notations, and abbreviations). when is code-first notation used? when two codes are used for one diagnosis. -a specific sequencing order with the underlying condition listed before the manifestation is required. what happens if only the manifestation code is entered on the claim form? the claim would be denied due to incorrect use of codes. what do you do when using ICD-10-PCS to locate procedures? reference the index first.. -the main term of the procedure will refer the coder to the appropriate table of the tabular, the table is used to build the code. how do you write a ICD-10-PCS code?

1. the first character matches the section where the procedure is classified(one of the 17 sections)
2. the 2nd-7th characters are defined by the section they are in.
3. any remaining characters where no other devices or qualifiers are used are Z. what's an example of a HCPCS level II code? A6412 (eye patch, occlusive, each) -this code is used when a patient receives an occlusive eyepatch, this level II code is submitted to the insurance carrier along with a CPT code as well. who develops, maintains, and owns the right to the copyright of the coding system? American Medical Association (AMA) How often is the CPT updated? Annually(every year)

how do insurance carriers reimburse multiple procedures? the first procedure in full and following at a reduced rate, usually 50%-75% of the cost. does HCPCS codes guarantee a service will be rendered? although used for billing, NO which codes are specific to Medicare? G codes how often are HCPCS codes updates? 4x a year as they are public domain and can be located on the CMS website what did the CMS design in order to assist in controlling erroneous coding billed to Medicare and facilitate correct coding methods? NCCI, National Correct Coding Initiative -their edits are used in outpatient services and providers' offices. -according to Medicare, any claims denied under NCCI edits are not allowed to be billed to the patient. what do EHRs interface with insurance carriers for? eligibility verification

another way is using a carrier's web-pased portal. what do providers subscribe to in order to decipher HETS information? to third-party payers since the system is challenging to understand. what does Medicaid provide? online eligibility database that is managed by each individual state. how do most portals provide verification? on a patient-by-patient basis what happens if referral approval is required? ask the patient to see a provider. what if preapproval is granted? the service or treatment must be medically necessary. -if not, payment may be denied after the claim has been submitted. what if authorization is delayed and the patient arrives for scheduled services? call the insurance carrier for verbal authorization. what do you document when giving authorization in the patient's EHR?

date, time, & name of patient what if authorization of services is not obtained? reschedule the appointment.

document the referral recommendation in the patient's record and send it to the referring provider as needed. who handles the preauthorization requests? the PCP, primary care provider what if a specialty provider originates the preauthorization? following up with the PCP may be necessary, as an authorization approval may be sent to the PCP. -set a maximum expected turnaround time and follow up on all requests within that time period. what if authorization is denied? the PCP office should contact the insurance payer and provide supporting documentation form the patient's medical record. what do you do once receiving an authorization? save, enter, or scan the form form every approved office visit, lab test, and treatment sequence. what happens once all approved services are completed? a new authorization must be requested if treatment is to continue. -must be done in a timely manner so the patient treatment is not delated. what do managed care insurance plans often require subscribes to obtain? lab or radiology tests at in-network organizations. why must you ask if a patient deductible applies when verifying benefits? because if the provider orders a lab or radiology service on-site, sometimes the patient does not have to pay the deductible. Precertification A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure. Preauthorization prior authorization from a payer for services to be provided. who might staff members contact to obtain authorization for treatment by specialty providers? the insurance carrier. what are patient cost estimates based on?

price info in the chargemaster and payer contracted rates. when must you provide patients with an estimate of their health care costs? before services are rendered for a timely payment. when would an advance beneficiary notice need to be given to a fee-for-service beneficiary? when a service exceed the limitation of liability. what are sent to patients who have insurance? a monthly statement for any outstanding balance where are patient statements generated from? the financial or billing sections of the EHR. how often are patient statements processed? actively each month or coordinated by a 3rd party vendor or billing company that processes the organization's financial activities and records. what might some organizations omit from patient statements? some specific info, like diagnostic and procedure codes. can patients pay bills online? YES, they can also have electronic statements and reminders sent securely through a portal and reduce processing and mailing costs. how may automatic online bill payments be set up? to charge patient credit or debit cards, expediting payment receipt and eliminating check-writing and postage. how are payments to third-party payers usually made? by direct deposit to designated account for the health care organization. what does a single deposit usually represent? payments for multiple patient claims, so it must be divided into multiple patient accounts based on payments made for each payment. where are posting instructions take from? the RA/EOB, are claims paid at 100%? rarely what will payment posting not to?

cover the amounts billed, which means additional accounting is required to ensure correct payment posting. what happens when payments are not correctly posted? the account will continuously have a balance. does a patient have to pay the deductible if they do not have surgery? NO, if they do have surgery, then the first $1,000 of allowed surgical charges are patient responsibility. -the insurance company will process the claim and apply the deductible amount to the patient. what is payment is denied, delayed, or ignored, or time limit has passed? contact the insurance company -if the matter is addressed over the phone, note the follow-up in writing, -posta copy of the note in the patient accounts, and in any tracking file or calendar. what do you do whenever an overpayment is made in error to a patient's account? note the activity on the appropriate patient account -also include documentation indicating to whom the refund was made, the date refunds were returned, and the method of refund. how do most facilities post payments? in real-time. -a day sheet can be used to reconcile patients' accounts collecting from patients: notify of anticipated charges -> collect at the time of service -> provide a receipt -refrain from generating patient statements until all payments are posted in the system and have been applied to the account. how can patient collections be performed? within an organization or tuned over to a collection agency. why must you verify that a EHR vendor will provide future support for bringing the system up to national standards? as legislation promotes interop. and new technology. who are guidelines for the content of health records set by? entities nationally recognized for clinical and public health expertise. what is the Uniform Hospital Discharge Data Set 20 elements required by? the U.S department of Health and Human Services (HSS) for all inpatient services billed to Medicare or Medicaid. what if you don't have two sets of standards---one for private and another for government payers?

it simplifies audit processes and the revenue cycle. what is a master patient index? The Master Patient Index identifies patients across separate clinical, financial and administrative systems and is needed for information exchange to consolidate the patient list from the various RPMS databases.

The MPI contains records for all the patients from all of the IHS facilities. when does the organization informs people of their rights? at their first encounter what does a business associate handle? they handle or use PHI's at the covered entity's request. what do many health care organizations hire to handle PHI? outside billing and outside accounting services in smaller organizations or clinics, who sends the reports to them? it can be an internal task or one the remote server host or EMR vendor manages. who do you direct any patient requests, questions, concerns, or grievances regarding PHI? to the privacy officer. what do user permissions prevent? unnecessary internal disclosures to limi the potential for data compromise from external sources. -it also may exclude or include the ability to download from the internet or allow software updates. what do EHR vendors provide training on? assigning user permissions. what does a system administrator or security officer assign? permissions as staff is onboarded or job responsibilities change. What is ransomware? A computer virus that encrypts a user's storage, until the victim pays money to unlock it with who may noncompliance with privacy and security policies occur among? IT and administrative personnel. who must all covered entities comply with? HIPAA to protect the privacy and security of health info and provide individuals with privacy rights in regard to their health info.

is a business associate agreement required with diagnostic of laboratories working with an organization to treat patients? it is NOT needed what is not essential when dealing with a business associate agreement? to have one with anyone whose services do not use of disclose PHI or anywhere PHI could be accessed incidentally. upon registration, what are patients asked to do? sign an authorization form to release health info in certain situations when should consent for treatment be obtained? in both an in & outpatient setting. what is general consent for a treatment? it is an agreement that the organization may perform treatment and care for the patient. what is consent for surgical procedures? the specialty provider must obtain informed consent prior to delivering the care. what is required when the provider covers the consent info and ensures the patient signature is documented? a witness. what will the organization complete for claims of submission, typically electronically? a CMS-1500 or a UB-04 form. what must you have the patient fill out? authorization forms to bill for services and ensure the provider signs it to keep it on file. -the third-party payer or insurance company will be informed that the patient authorized the provider to receive insurance payments directly. what can the provider indicate when submitting claims for reimbursement? a "Signature on File" (SOF). -this saves time and reduces paperwork and encourages payers not to hold up reimbursement due to an outstanding new signature with every claim. what can one signature on file do? remain in place for future claims. -health care organizations often update patient signatures annually. how quick can an organization be back and running? depending on the downtime cause, as little as a few hours.

what must a provider's documentation during a patient's visit be complied into? text format to create an encounter summary report. which information is collected to produce structured reports? info recorded using preconfigured fields or codes, which then a provider can use to identify trends in a patient's condition. -the info is then used to identify interventions to improve the patient's outcome. ex: if the provider is able to track trends in a specific laboratory and compare them to concurrent medication adjustments, the patient can maintain the most effective dosage of medication. what does the RIS interface with? the picture archiving communication system (PACS), where an image is stored. how does a radiologist interpret an image? by dictating a report using a voice recognition program connected to the RIS. -this creates a clinical report for the x-ray study and a link to the images in the EHR, where they can be viewed as needed. what do many EHR systems have that can help a provider when interpreting an image? color-coded images or icons that alert the provider of critical lab values how can performance reports be generated? using specifying data points in a search, system locations covered by the search, and how data will be assessed. in an outpatient environment, how may reports be created? to determine if an organization meets quality indicators for preventative care. -the reports may include info on interventions such as screenings recommended for patients by sex, age, or history to determine if interventions were performed appropriately. HITECH act of 2009 -tracking and reporting quality measures gained national importance with this -it also promotes the use of EHRs in the health care industry what are statistical reports, like trend analysis used for? to predict the spread of diseases and identify actions that can have positive outcomes for the patient. what are systems designed with to reduce the likelihood of errors? interoperability features such as automatic uploading of clinical data from other systems into the EHR Which of the following actions would generate a real-time alert message in the EHR? The provider enters a prescription for a duplicate therapy.

Which of the following components of a Subjective, Objective, Assessment, Plan (SOAP) note would pull in real-time test results from the EHR? Objective(observes real-time results). how does the registration process begin in an outpatient setting? when a new patient calls the office for an appointment to see a provider. what does a front staff member do once they obtain information from a new patient? they create an account that includes the patient's identity, medical condition, and insurance/payment info. what does a front staff member do once they obtain information from an established patient? the staff member searches for the patient record by using demographic data

once the data is verified, followed by a review and update of the patient's insurance or third party payer, and the guarantor on the account. what happens once the financial data is verified? the patient is given a NPP, and other documents like an advance directive and assignment of benefit forms. what is a notice of privacy practices (NPP) form? a document that is required by law to inform a patient how an organization will use their health care information. what is an advance directive? a legal document that contains information about a patient's treatment choices when they are unable to make health care decisions. what is an assignment of benefits form? a patient's authorization to allow health insurance payment to be made directly to the provider of service. how are patients registered in an ambulatory setting? the patient info is used to generate wristbands, which are used for identification and can display health info. what are color coded wristbands? they are used to alert providers of allergies, blood type, or DNR. what clinical information are entered by providers and support staff? review of systems, physical examination, diagnosis, and treatment are all included in an encounter note.

what is internal data? it is recorded by providers(sometimes patients) during an encounter. what is included within internal data? financial information entered during scheduling and patient registration to enable reimbursement for services. what is external data? (digital images, lab results) often starts outside the office where the patient record lives.

directing info into the patient's electronic record helps create complete record of the patient what is common to find in a fully integrated EHR environment? only electronic documentation of all patient care data, these organizations might maintain paper records only from before the EHR was adopted. what do patient kiosks allow? patients to sign into the waiting room using a computer.

this enables patient demographic data to be available in the system before they are called.

the preloaded clinical data is displayed to the provider as a starting point to engage the patient in care. what are peripheral devices? ex: bar code scanners, cameras, printers, signature pads, fax machines.

they are used to obtain and record patient info, especially when transitioning from paper-based transactions to electronic systems. what are electronic signatures used to do? capture patient signatures.

they record patient acknowledgements and consents for treatments, as well as patient responsibility for service charges. what does the practice management software keep record of? appointments, hence no paper logs or books.

can be used to complete patient registration as well. how is patients insurance documentation verified? through web portals

what is the responsibility of the front staff? to schedule appointments and perform patient check ins. what can the clerical staff assist with? coding or billing of services provided during an encounter how do some offices start the workflow? with patient-entered data where the patient logs in and populates PREregistration what happens once the info is verified by the front desk? the patient's arrival is electronically confirmed and a notification is generated to inform the provider that the patient is ready to be seen what are electronic devices used to measure? the patient's vital signs, and results, as they are immediately recorded into the EHR. who can see a patient's EHR? anyone involved in the treatment of the patient, the subjective and objective data at the point of care can be seen by other providers. what if a provider requests a referral? a template can be used to enter the info for the referred provider to review. how can a patient present for inpatient admission? emergency department or surgery department

also after an office visit or if a patient was transferred from another facility how does inpatient workflow begin? with recording demographic data and identifying the patient as an active care recipient in the system. what may physical, speech, and occupational therapists provide? rehabilitation services and document patient progress in the EHR. how are test results from laboratory diagnostics transmitted? from the LIS into the patient record to enable multiple providers to access data when making treatment or care decisions.

the LIS interfaces with the EHR system to deliver results to the patient's record. how is laboratory testing batch processed? by entering info into an automated analytical instrument where the evaluation of the sample is completed.

what do hospitals that have a radiology info system (RIS) commonly user? a PACS, picture archiving, and communication system to store and report results of diagnostic imaging. where are electronic orders entered by providers in clinics transmitted? to the RIS, and patient images are captures during a test.

the image stored in the PACS is associated with the order in the RIS.

a report is then generated from the radiologist's interpretation of the image, and the report is automatically transferred to the EHR. what are IT professionals enlisted to enable? interoperability and data exchange with other systems,

it prevents delays in treatments. how is real-time data trasnmitted? from one unit to another, enabling users to make decisions of follow-ups to speed up delivery of care.

observing standards or protocols also promotes safe transfer of data for quality, cost- effective care. Laboratory Information System (LIS) receive pathology orders & transmit results from the analyzer to EHR. -can also generate reports on laboratory results Computerized provider order entry (CPOE) enable valid ID to match the prescription with the patient. Practice management system (PMS) manages revenue cycle processes & appointments picture archiving and communication system (PACS) store images of diagnostic tests & interpretations of studies. Radiology Info System (RIS) transfer imaging orders & patient data to testing devices. how is training for clinical staff commonly administered? by trainers or staff from the IT department during the implementation phase. what do other organizations used to train staff? vendors as part of the functional testing of the system.

how is training in organizations with multiple clinic locations? they are generally centralized, it is common to find trainers from the IT department assigned to provide education on specific days to newly hired staff from more than one clinic. how is training in smaller outpatient organizations? localized, offices may use social media to deliver training. what do other offices use? job training approaches, which may include using existing employees as superusers to train new staff. what do training on hardware tools include? input devices (touch screen, bar code, camera, or optical scanner).

output devices include how to securely display information on computer monitors, speakers, and printers without undue exposure of patient data. what are administrative safeguards of data? training staff on security awareness through reminders, protections from malicious software, and log-in and password management. how can security reminders be communicated? electronically, verbally, or via documents what extra layer of security is instituted with passwords? the system automatically blocks a user from accessing the system after a specific number of unsuccessful login attempts.

the user must contact the administrator or technical staff to enable access to be restored. how must passwords be situtated? strong password = lower/uppercase letters, & special characters. what does the provider enter to represent the treatment given or service provided? a CPT code. what are the revenue cycle staff trained to do? access system functionalities (appointment scheduling, billing & coding, dashboards, revenue cycle administrative tools). what do organizations with CPOE systems usually have? a PIS, pharmacy information system where do providers enter prescribed medications?

it is printed on prescription paper (Rx), then it is signed and sent to the pharmacy via fax for processing.

using the CPOE, and the pharmacist verifies the meds for allergies or contraindications.

after the pharmacy dispenses the meds, records of the meds are scanned into the patient's EHR by the HIM staff.

*the medication has a bar code that the nurse scans for accuracy.

*the patient's wrist band is also scanned to match the info on the eMAR. where are alerts like CPOE and non-coverage generated? they are coordinated to include info stored in LIS & PMS how do billing staff adjust the charge entry form? as appropiate to generate claims for reimbursement of services. what is the process of E&M with a provider? the provider reviews the diagnosis and procedure codes, accepts it, and signs off to complete the encounter documentation.

the EHR system automatically transfers the info to the billing software or PMS, where the billing staff review and post the charges.

*this minimized billing errors and discrepancies. what happens if there's an error in billing? the provider receives an electronic message to correct the error prior to billing.

info in the electronic message will state a time within which the mistake or incomplete entry must be fixed. what does a personal health record (PHR) enable a patient to do? engagement in managing their health and conditions.

a patient communicates with providers involved in decisions affecting their care.

a patient has access to a patient portal to view their medical record. how do patients access their portal? a web link and instructions on how to register is given. what are patient portals designed to do?

as a patient logs in and chooses a virtual office visit, it verifies identity and confirm coverage

insurance copayments are collected, and once they are checked in for a virtual visit, they are prompted to complete clinical info, like history and reason for visit.

all documentation is recored in real-time. what is the 3 year rule? a patient is determined "new" if they had a previous face-to-face service in the last 3 years from the date of service. how do health care organizations integrate paper documents into EHR systems? by scanning them as images, which are uploaded into the patient's EHR.

ex: insurance cards are scanned into a system as well as other documents NPP, vaccine consent forms, etc, once the patient has reviewed and signed them.

prevents fragmentation of patient's record how are scanners integrated in a clinical realm? faxed reports of diagnostic results (lab/imaging results) are scanned and uploaded into an EHR.

scanned documents are labeled and coded with info that enables users to locate the, in the system. how can the process of image cataloging be automated? using barcoding or optical character recognition (OCR) software. what does barcoding do? it automatically labels the scanned image by document type, patient, and date, which makes the document easier for the user to locate. how can the optical character recognition be used? to find text within the scanned document, which is then stored within the image in the system. what's a downside with scanned information? it is often not searchable.

reports, alerts, health maintenance, and data exchange cannot be generated from scanned documents. what's a solution to a scanner downside? to use links to connect diagnostic images on external systems directly to the EHR. how are standard efax technology used in an outpatient environment?

the send a receive patient info. what are cameras used to capture? clinical data such as rashes, abnormal growths, abscesses, and ulcers

for other data, patient photographs for physical ID

*MUST seek approval to use photograph, so privacy rules are not violated. where are camera images captured and recorded? they can be saved and transferred from other systems into the electronic medical record (EMR).

the EMR allows image uploads. what are bar codes used for? patient ID and prevents medical mistakes. what are on barcode wristbands? patient's name or MRN, they are used to ID patients prior administering meds or during surgical procedures. what can a bar code scanner do? read the info on the band and compare it with data in the system to ensure that the correct patient is receiving treatment. how does a clinical staff use bar code technology in an outpatient setting? to administer and document vaccines and injections prescribed for pain, inflammation, and other conditions. how does the process begin with barcode technology? the prescriptions are written in a CPOE system, and it ends with administration and automatic documentation of the medication, full name and DOB. how are the identity of infants and nonverbal patients verified? a caregiver, partner, parent, etc. how are prescription medications dispensed? with a bar code on the medication package.

health care professionals scan the patient wristband and the medication bar code. what happens if there is an incorrect doasge, time of administration, or patient? an alert is generated

what happens are a medication is scanned and verified in the computer? since bar code technology also makes charting easier, the user's login status serves as the signature for the eMAR. Health Information Technology (HIT) Use of technology as a resource to manage patient health care information. Protected Health Information (PHI) Individually identifiable health information that is transmitted or maintained by electronic media or in any other form or medium What is considered Protected Health Information? (PHI) Name, names of relatives, address, employers, social security number, phone, fax number, email address, health plan identification number, account number, fingerprints, website address, medical record number, serial number of vehicles and photos. Electronic Health Record (EHR) Computerized lifelong record health care record with data from all sources. Technology that intertwines health information from a variety of sources of every encounter an individual has with the health care system is documented. Lab, scripts etcetera. New position created by EHR Clinical Analyst Health Information Technician Records and information coordinator What setting may a CHERS work? Doctors office labs Ref Labs Urgent Care Centers Nursing Home Facilities Wellness Clinics Hospitals Why were chances in technology made? From the realization that medical records were not meeting the needs of doctors & patients. Increase in errors, rising health care costs and missing link in a patients coordination of care. Current Procedural Terminology (CPT) System of classification for services and procedures used in the outpatient setting. Medical Errors Among most common causes of death, occur because:

1. Lost medical records
2. Miscommunicated patient request/messages
3. Unreadable information due to poor handwriting
4. Mislabeled lab specimens.
5. Many of these errors could be overcome if information tech were applied throughout healthcare system.

What potential does Health Information Technology have? (HIT) Improve the quality of care and possibly reduce the number of deaths attributed to medical errors. HIPPA require the use of electronic rather than paper in claims? Oh baby. Yes! Yes! Yes! Standards Commonly agreed upon specifications, are what helped establish the requirements necessary for agencies to follow. When did President Bush recommended the use of Health Information Technology? (HIT) In 2004 What was the goal of Health Information Technology? (HIT) Set a ten year goal for all Americans to be using Electronic Health Records. (EHR) Who or what was established to meet this goal? Office of National Coordination for Health Information (ONCHIT) HITSP A department / organization that identified standards for exchange of health information. What does the Nationwide Health Information Network provide? (NHIN) Links medical records across the country. CCHIT Developed certification criteria for EHR software. What 8 core functions does the Institute of Medicine suggest an EHR should include?

1. Health Information and data elements
2. Results Management
3. Order Management
4. Decision Support
5. Electronic communications and connectivity
6. Patient Support
7. Administrative Processes
8. Reporting and population management Medical Record An important business document used to support treatment decisions documents services provided could also be used in court of law for evidence purposes. Electronic Medical Record (EMR)

Computerized records of one doctor's encounter with a patient over time including medical history, diagnosis, treatment and prognosis. What is the contrast between EMR's and EHR's? EMR's reflect treatment of a patient by one doctors as EHR reflects data from all sources that have treated and individual. Personal Health Record (PHR) Maintained and owned by the patient, patient makes decisions whether to share contents with their doctors. Electronic Health Record (EHR) Computerized lifelong record health care record with data from all sources technology that intertwines health information from a variety of sources every encounter an individual has with the health care system is documented. Labs, scripts, ER visits, etcetera. New position created by EHR Clinical Analyst Health Information Technician Records and information coordinator. What setting may a CHERS work? Doctors office labs Ref Labs Urgent Care Centers Nursing Home Facilities Wellness Clinics Hospitals Why were chances in technology made? From the realization that medical records were not meeting the needs of doctors and patients. Increase in errors, rising health care costs and missing link in a patients coordination of care. What was HIPPA designed for? Enacted in 1996, designed to protect patients' private health information, ensure health care coverage when workers change or lose their jobs, and uncover fraud and abuse in health care systems. True or False. HIPPA requires the use of electronic rather than paper insurance claims? True Acute Care Most often refers to a hospital, treats patients with urgent problems that cannot be handled in another setting. Hospital records keep track of time-limited episodes where doctor's charts reflect the ongoing health of individual. Inpatient treatment. Ambulatory Care Refers to treatment without admission to the hospital. What are the advantages of EHR's? Safety Quality of Care Efficiency Cost Reduction