Kinn's Administrative Medical Assistant Chapter 12 Study Guide
What is the approximate cost of implementing an EHR system for a typical physician's office with five physicians?
$162,000 with $85,000 going to maintenance during the first year
Mary Elizabeth Smith called the physician's office to report redness around an injection site. She was in the office 3 hours ago and received an injection of penicillin. She says she also is itching quite a bit around the site and is having trouble breathing. The doctor has left the office for the day. Office policy states that if the physician is out of the office and a patient presents or calls with an emergency, he or she is to be referred to the ER. Document the action that the medical assistant should take.
05-02-2018 10:00 AM Patient called 3 hours after leaving the clinic and receiving an injection of penicillin. Patient says the injection site is red and itchy and she is having trouble breathing. Doctor has left the office for today, per policy referred patient to ER. M. Smith, CMCS
Angela Adams called to report that she was not feeling any better since her office visit on Monday. She wants the doctor to call in a refill for her antibiotics. The chart says that she was to return to the clinic on Thursday if she was not feeling better. Today is Monday, and she says she cannot come into the clinic this week. The physician wants to see her before prescribing any other medication. Document this information.
05-02-2018 10:00 AM Patient called to report she was not feeling any better since her office visit Monday a week ago. The patient wants the doctor to refill her antibiotics. She was to return in three days if she wasn't feeling better. The physician would like to see her before prescribing any other medication, the patient cannot come into the clinic this week. M. Smith, CMCS
Eric Robertson canceled his surgical follow-up appointment today for the third time. Document this information
05/02/20XX 12:55 PM Patient canceled his surgical follow-up appointment today for the third time. M. Smith, CMCS
The patient stated that the chest pain began 2 weeks ago. 1-31-20XX 10:00 AM Patient complained of chest pain for the past 2 months. No pain noted in arms. No nausea. Desires ECG and blood work to check for heart problems. R. Smithee, CMA
1-31-20XX 10:00 AM Patient complained of chest pain for the past 2 weeks. No pain noted in arms. No nausea. Desires ECG and blood work to check for heart problems. R. Smithee, CMA
List five advantages of an EHR system
1. Easy storage of patient information 2. accessibility by multiple users at the same time 3. making electronic claim submission a more a efficient process 4. federal government has offered financial incentives 5. fewer errors
List five disadvantages of an EHR system.
1. lack of capital 2. fear of something new 3. startup costs 4. space for equipment 5. training necessary
List 5 reasons why medical records are kept.
1. the health record helps the provider provide the best possible medical care for the patient 2. the health record also provides critical information for others 3. health records are kept as legal protection for those who provided care to the patient 4. health records provide statistical information that is helpful to researchers 5. health records are vital for financial reimbursement
List and explain the five basic filing steps.
1. the papers are conditioned, which is the preparatory stage for filing 2. the documents are released, which means they are reviewed and marked and ready to be filed 3. the documents are indexed, which involves deciding where each document is to be filed and coding it to mark the indication of that decision 4. sorting, placing the files in filing sequence 5. the actual filing and storing of documents
The correct date of the appointment below was October 12, 20XX 10-21-20XX 1330 Patient did not arrive for scheduled appointment. P. Smith, RMA
10-12-20XX 1330 Patient did not arrive for scheduled appointment. P. Smith, RMA
By what other name is the American Recovery and Reinvestment Act known?
Economic Stimulus Package
What does HITECH stand for?
Health Information Technology for Economic and Clinical Health
Bruises on upper arms:
Objective
Elevated blood pressure:
Objective
Weight of 143 lbs:
Objective
Yellowed eyes:
Objective
Define the following terms: a. Reasonable cause b. Reasonable diligence c. Willful neglect
Reasonable Cause - circumstances that make it unreasonable for the covered entity to comply with the administrative simplification provision that was violated Reasonable Diligence - the care and prudence expected from a person seeking to satisfy a legal requirement under similar circumstances Willful Neglect - conscious, intentional failure or reckless indifference to the obligation to comply with the administrative simplification provision violated
Complaint of headache:
Subjective
Insurance information:
Subjective
Patient's address:
Subjective
Patient's e-mail address:
Subjective
Patient's phone number:
Subjective
Discuss how you would talk with a patient who has expressed legitimate fears about having health information in electronic form. Explain what you would say to the patient and how you would reassure the individual.
There are many regulations in place that are followed to a "T" to make sure all electronic information is secure
tickler file
a chronologic file used as a reminder that something must be dealt with on a certain date
subpoena duces tecum
a court order to produce documents or records
indirect filing system
a filing system in which an intermediary source of reference (e.g., a file card) must be consulted to locate specific files
direct filing system
a filing system in which materials can be located without consulting an additional source of reference
microfilm
a film with a photographic record of printed or other graphic matter on a reduced scale
caption
a heading, title, or subtitle under which records are filed
retention schedule
a method or plan for retaining or keeping health records and for their movement from active to inactive to closed filing
patient portal
a secure online Web site that gives patients 24-hour access to personal health information using a username and password
pressboard
a strong, highly glazed composition board resembling vulcanized fiber; heavy card stock
outguide
a sturdy cardboard or plastic file-sized card used to replace a folder temporarily removed from the filing space
provisional diagnosis
a temporary diagnosis made before all test results have been received
transcription
a written copy of something made either in longhand or by machine
Julia prefers a(n) ______ filing system, in which the letters of the alphabet are used to identify a file.
alphabetic
Describe the indexing rules for alphabetic filing.
alphabetic filing by last name, first name
Veronica prefers a(n) ________ filing system, in which combinations of letters and numbers are used to identify a file.
alphanumeric
quality control
an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries
electronic health record (EHR)
an electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and can be created, managed, and consulted by authorized clinicians and staff from more than a single healthcare organization
electronic medical record (EMR)
an electronic record of health-related information about an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization
personal health record (PHR)
an electronic record of health-related information about an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources but that is managed, shared, and controlled by the individual
parameters
any set of physical properties, and values of which determine characteristics or behavior
alphabetic filing
any system that arranges names or topics according to the sequence of letters in the alphabet
reverse chronologic order
arranged in order so that the most recent item is on top and older items are filed further back
Teresa wants to ___________ the current software library with programs for making brochures and designing websites.
augment
The office manager is particular about the ___________ under which documents are filed because she wants to be able to access information quickly.
caption
reasonable cause
circumstances that would make it unreasonable for the covered entity, despite the exercise of ordinary business care and prudence, to comply with the administrative simplification provision (part of Health Information Technology for Economic and Clinical Health Act [HITECH]) that was violated
A process of electronic data entry of medical practitioner or provider instructions is called ______________ _______________ ______________ ________________.
computerized provider/physician order entry (CPOE)
continuity of care
continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care
Meriting condemnation, responsibility, or blame for an act is called _______________________.
culpability
objective information
data obtained through physical examination, laboratory and diagnostic testing, and by measurable information
subjective information
data or information elicited from the patient, including the patient's feelings, perceptions, and concerns; obtained through interview or questions
Identify the categories used for organizing information in a POMR system.
database: includes chief complaint, present illness, patient profile, review of systems, physical exams, and laboratory reports problem list: a numbered, titled list of every problem the patient has that requires management or workup treatment plan: management, additional workups needed and therapy progress notes: structured notes that are numbered to correspond with each problem number
Dr. Weaver uses _________ for the information needed for the patient's progress notes.
dictation
Identify equipment and supplies needed to create, maintain, and store health records.
divider guides file folders labels space for filing
requisites
entities considered essential or necessary
Explain the contents of Subtitle D of the HITECH Act.
established categories of violations increasing levels of culpability penalties determined based on nature and extent of violation established tiers of increasing penalty amounts
List three backup systems for the EHR system in a physician's office.
external hard drive full server backup online backup system
List several things to remember when in the examination room with the patient and the electronic device that houses the EMR system. Specifically, what should you do, as the medical assistant, to put the patient at ease?
eye contact, do not shield the device from the patient, modify your stance so patient feels like a part of the process, offer choices whenever possible, never expect patients to make quick decisions about their care
gleaned
gathered bit by bit (e.g., information or material); picked over in search of relevant material
vested
granted or endowed with a particular authority, right, or property; to have a special interest in
The electronic record that originates from more than one facility is called the electronic ___________________ record.
health
A system that is capable of interacting with another system is said to be ____________________.
interoperable
The electronic record that originates from one facility is called the electronic _______________ record.
medical
culpability
meriting condemnation, responsibility, or blame, especially as wrong or harmful
Paula Ann believes that only a(n) _________ filing system provides patient confidentiality
numeric
The clinic physician records ____________ information when examining the patient.
objective
_______________________ is never acceptable in health records because it obscures the original entry.
obliteration
Identify the method of organizing information in an SOMR system.
observations and data are cataloged according to their source--provider (progress notes), laboratory, radiology, hospital, or consultant. progress notes and forms are filed in reverse chronologic order and in separate sections of the record according to the type of form or service rendered
alphanumeric
of or relating to systems made up of combinations of letters and numbers
What two major types of patient records are found in a medical office?
paper and electronic
The values that determine characteristics or behavior are ______________.
parameters
Define meaningful use.
providers must show they are using EHR technology in ways that can be measured significantly in quality and quantity. If providers meet qualifications, they qualify for financial incentives
Dr. Lupez's _______________ ________________ was irritable bowel syndrome, not colon cancer.
provisional diagnosis
The 2009 modifications to HIPAA established increasing levels of ______________ for violations.
reasonable diligence
Jose read the memo about the new medical records _________________ __________________ with interest because his job includes filing.
retention schedule
Briefly describe three of the capabilities of an EHR system. Why do you think each capability will enhance patient care?
specialty software: patient data are captured and processed into a specialty specific system appointment scheduler: allows staff to track, schedule, and block times for each day medical billing system: manages all of the practice's billing and accounting systems, and can also interface with clearinghouses for claim submission and tracking
The clinic physician records _______________ information when questioning patients about their illness.
subjective
Bloated stomach:
subjective/objective
The healthcare facility received a __________ _______________ _____________ that requires them to bring a patient's medical record to court.
subpoena duces tecum
interoperability
the ability to work with other systems
obliteration
the act of making undecipherable or imperceptible by obscuring or wearing away
dictation
the act or manner of uttering words to be transcribed
age of majority
the age at which a person is recognized by law to be an adult; can vary by state
reasonable diligence
the business care and prudence expected from a person seeking to satisfy a legal requirement under similar circumstances
Describe the difference between an EMR and a practice management system.
the electronic medical record (EMR) is an electronic record of health-related information about an individual that can be created, gather, managed, and consulted by authorized clinicians and staff within a single healthcare organization the practice management system is an application that manages the operation of the medical practice
numeric filing
the filing of records, correspondence, or cards by number
Explain the concept of the ownership of medical records.
the owner of the physical health record is the provider or medical facility, often called the "maker," that initiated and developed the record. The patient has the right to access the information within the record but does not own the physical record or other documents pertaining to the record. The patient has a VESTED interest and therefore has the right to demand confidentiality of all information in the record
computerized provider/physician order entry (CPOE)
the process of entering medication orders or other provider instructions into the electronic health record (EHR)
purging
the process of moving active files to inactive status
Why might color-coded files be more efficient than an alphabetic filing system?
the use of color visually restricts the area of search for a specific record, a misfiled record is easily spotted even from a distance
e-prescribing
the use of electronic software to communicate with pharmacies and send prescribing information, taking the place of writing a prescription by hand and physically giving it to a patient; most new or refill prescriptions can be submitted electronically, cutting down on fraud and errors
Define and explain e-prescribing.
the use of electronic software to communicate with pharmacies and send prescription information
Dr. Banford uses a(n) ______ file to help him remember that a certain action must be taken on a certain date.
tickler
augment
to increase in size or amount; to add to in order to improve or complete
alleviate
to partly remove or correct; to relieve or lessen
Brigitte uses _________________ to put Dr. Weaver's information into the electronic health record (EHR).
transcription
Both the patients and providers have a ________ interest in the information contained in the health record.
vested
A conscious, intentional failure or reckless indifference to an obligation is called _____________ ______________.
willful neglect