Ch. 4-6 Electronic Health Record SimChart
Chief complaint
A brief statement of the problem, condition, or symptoms that prompted the patient to seek medical care
secure fax
A fax transmission sent via secure email
Hybrid
A medical practice in which health records are stored using some combination of paper and electronic media
High-alert medication
A medication that poses a heighten risk of injury or death when improperly administered
Virtual private network (VPN)
A pathway that allows encrypted data to travel securely through an internet connection to its destination, where it is encrypted.
waiting room
A period of time reserved for a patient to see a healthcare provider.
E-visit
A physician consultation with an established patient using a secure internet service
Client-server model
A platform in which a powerful central computer serves a network of connected PC's or other workstations.
telephone etiquette
A polite, helpful response and respectful manner toward callers
patient flow
A product of accurately estimated patient volume, a consistent provider pace, and efficient scheduling practices
Chronic condition
A prolonged illness that requires periodic follow-up
Workflow
A set of related tasks necessary to complete a step in a business process
Controlled vocabulary
A standardized list of preferred terms and corresponding codes for medical diagnoses, finds, procedures, services, and treatments
secure email
A system capable of transmitting an encrypted message and storing it in codes format until it is retrieved by the recipient via a secure web link
encryption technology
A system that keeps data secure by converting it into an unreadable code during transmission and then encrypting the information when it reaches the recipient
Acute condition
An epicodic illness or injury of limited duration that respons well to treatment
Legacy EHR
An existing, functional EHR system scheduled to be replaced with a newer software application.
Review of systems
An organized inventory of each organ system
Software vendors should be the practice's only source of information about the product because no one knows the application better.
F
The HIPAA Privacy Rule allows medical practices and other covered entities to disclose some healthcare information via email fax or phone without specific patient authorization, provided precautions are taken to protect privacy
F
The best approach to training is a sink-or-swim attitude because users learn best when they have to figure things out for themselves.
F
The chief complaint includes all health concerns a patient is seen for during the course of a physician's visit
F
To simplify the implementation process, only key decision makers and a staff representative should be involved.
F
Use of a script is a helpful way for patients to understand that the physician has reserved specific time for them.
F
Voice recognition software does not eliminate the need to transcribe the provider's office notes.
F
Workflow redesign will not be addressed until the EHR system goes live.
F
You should avoid apologizing to patients because doing so constitutes an admission that the practice has made a mistake
F
speech recognition software can distinguish one voice from another.
F
Subjective
Perceived only by the patient and not evident to or measurable by the clinician
Template
Predefined, customizable forms that speed structure data collection
Objective
Readily seen, perceived, or measured by the clinician
A medication list must be reconciled and update in the EHR during each patient encounter.
T
Alwats set up the patient EHR account using the name listed on the insurance or ID card.
T
Appointment slots should be blocked out for trips, holidats, or out-of-town time using the Block Appointment type
T
Audits should be conducted both randomly and at regular intervals under security plans.
T
Backing up data in the patient's EHR is mandated by HIPAA
T
Client-server platforms are generally more expensive to start up that ASP licensing arrangements.
T
Electronic misfiling is the digital equivalent of physically misfiling a document.
T
Fraud can occur if an EHR is not properly designed to accommodate the practice's financial documentiation
T
HIPAA-compliant secure email services may also offer web hosting services, spam filtering, virus protection, and related accessories, such as shared calendars and address books.
T
Many errors in EHR medication lists are attributable to patients' confusion about drug names and dosages
T
Over-documentation can leave a provider vulnerable to charges of fraud and abuse.
T
Several users can access the electronic appointment book at once
T
The digital signature helps ensure the security of the patient's information.
T
patient instruction should be performed in well-lighted area with limited distractions.
T
History of the present illness
The duration, location, severity. context as a symptoms that prompted to the patient to see medical care.
appointment slot
The first stop in a patient's path through the medical office
Anthropometric measurements
The height, weight, and size of the human body
show rate
The percentage of patients in a practice who arrive for appointments as scheduled or call in advance to cancel or reschedule
retention
The period of time patient records must, by law, be maintained by the medical office
purging
The process of separating inactive patient health records from active ones
Organizational culture
The shared set of values, beliefs, and assumptions that governs behavior and decision making within a healthcare practice
Records Management
The systematic control of patient records, from creation through maintenance and storage
Go live
To leave the practice mode and become operational
Physicians using the EHR must use a structured method of data entry.
F
Providers starting before moving on to stage 2.
F
Cloning
Copying and pasting information from a previous entry in the patient's record or from another patent's record
views
Different ways of displaying the same or similar information on a computer screen, usually with increasing or decreasing detail
A legacy EHR is a failed EHR system left behind when the staff gives up on learning how to use it.
F
A medication reconciliation should be performed when a patient is removed from the operating room to the recovery room.
F
A patient is asked for his or her allergy history only during each patient encounter.
F
E-visits are illegal in most states.
F
EHR users should find the scheduling view that works best for their office and ask the administration to program it in permanently
F
HIPAA compliance and security features should be considered in choosing an EHR system.
F
Immunization status and administration need not be recorded for patients ages 18 or older.
F
Interfacing has made incompatible systems a thing of the past because all systems are now interoperable.
F
Patients are unlikely to notice the conversion from paper to an EHR.
F
Unstructured data entry
Free-text keying of data directly into the electronic record
double-booking
Giving two or more patients the same appointment time with the same provider
