CH 5 HRS

True

Images that are stored electronically can enable retrieval of records rapidly.

bar codes

Machine-generated identification codes.

record transitional template

A document that delineates the various sources of the component parts of the patient's record and assists in the transition from paper to electronic formats.

False. A hybrid record is part paper and part electronic record.

A hybrid record is electronic.

operating software

A set of computer programs that control hardware and interface with application software.

False. A patient monitoring system includes systems that allow for the continuous monitoring and collection of vital signs.

A vital signs monitoring system includes systems that allow for the continuous monitoring and collection of vital signs.

True

After a document is final saved, the document must not be altered.

clinical data repository

Allows for the collection of all clinical data in one centralized database, and provides easy access to data in electronic or printed form to the patient's clinical history.

electronic medical record (EMR)

Automated record system that documents patient care using a computer with a keyboard, mouse, optical pen device, voice recognition system, scanner, or touch screen. Records are often created using vendor software, which also assists in provider decision making and is most commonly associated with office practices that need practice management solutions.

False. No two facilities have the same EHR system since various facilities have combinations of various systems.

EHR systems are the same for each facility.

software

Program used to operate a computer and perform functions.

document imaging

Provides an alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved on storage media; also called document imaging.

optical disk imaging

Provides an alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved on storage media; also called document imaging.

Health Information Technology for Economic and Clinical Health Act (HITECH)

Provides incentives through the Medicare and Medicaid EHR Incentive program.

data

Raw facts that are not interpreted or processed (e.g., numbers, letters, images, symbols, and sounds).

False. Raw facts that are not interpreted or processed, such as numbers, letters, images, symbols, and sounds, are referred to as data.

Raw facts that are not interpreted or processed, such as numbers, letters, images, symbols, and sounds, are referred to as information.

longitudinal patient record

Records from different episodes of care, providers, and facilities that are linked to form a view, over time, of a patient's health care encounters. It facilitates clinical decision support and analysis of diagnoses, treatments, and illnesses.

RHIO

Regional Health Information Organization

True

Scanned pages are indexed, which means they are identified according to a unique identification number, which is commonly the patient's medical record number.

patient monitoring system

System that collects and monitors patient physiological data and records the information.

meaningful use

Term used as part of the HITECH legislation that outlines the requirements providers must meet in order to receive incentives for using electronic health records.

computerized medical records

Term used in 1970-1980 to describe early medical record automation attempts.

True

The Joint Commission standards state that inpatient hospital records must be completed within 30 days after discharge regardless of the storage system.

False. The IOM and HL7 developed standards that relate to the exchange of clinical health information.

The standards for the exchange of health information are being developed by AHIMA.

networking equipment

The wires, modems, routers, and cables that are used to connect an information system.

scanner

Used to capture paper record images onto the storage media and allows for rapid automated retrieval of records.

alerts

What is one of the key features in an electronic health record that is not available in a paper system?

Personal Health Record (PHR)

Which is an electronic or paper medical record maintained and updated by an individual for his or her own personal use?

Patient monitoring system

Which of the clinical health record applications would include the temperature, pulse, blood pressure, and respirations?

Scanner

Which piece of equipment is used to capture paper record images onto electronic storage media?

Patient Monitoring System

Which system collects and monitors patient physiological data and records the information?

1970s 1980s records were called

electronic medical records, longitudinal record, personal record

indexing

prepping for scanning a document

True

Health data is comprised of health facts that are collected about a patient or group of patients and that describes a health issue.

health information

Health data that has meaning and has been processed or organized in a manner that is useful for decision making.

Health Level Seven (HL7)

Standards development organization that develops electronic health record (EHR) standards under the direction of the U.S. Department of Health and Human Services.

True

A clinical data repository is a centralized database which provides easy access to data in electronic or printed form.

True

An application system that includes ordering of laboratory tests, the reporting of test results, and report generation is known as a laboratory application

bar code reader

An input device that reads a bar code and identifies a document as belonging to a specific patient.

registration-admission-discharge-transfer system (RADT)

Centralized database of patient demographic information that is used during processing of inpatient admissions and discharges.

record

Collection of related fields.

file

Collection of related records.

application software

Computer programs that allow the user to perform a particular task or function.

information

Data that has meaning and is useful in decision making.

regional health information organization (RHIO)

Electronic network of medical information about patients, which was gathered from multiple health care organizations in a geographic region.

personal health record (PHR)

Electronic or paper medical record maintained and updated by an individual for his or her own personal use.

input device

Equipment that allows users to enter information into the computer system, including the keyboard, the mouse, scanners, microphones, and cameras.

output device

Equipment that allows users to print or display information produced by a computer system, including printers and computer screens.

health information exchange (HIE)

Exchange and access to patient information generated by other facilities.

field

Group of characters.

U.S. Department of Health and Human Services

Health Level Seven (HL7) is a standards development organization that develops EHR standards under the direction of what department?

PHR

Personal Health Record

patient portal

Special application that provides patients with secure access to their electronic health information and patient-provider communication tools.

information governance

The creation of organizational wide policies, principles, and practices that focus on the management of information that is produced by the various systems within the health care organization regardless of the type of media used.

data governance

The creation of policies, processes, and procedures that focus on the management of data and information that relates to patient care and the operations of the health care organization. The primary focus of data governance is to focus on data accuracy as it is created within a system.

True

The original record and amendments to a patient record will show in the EHR.

February 9th

The patient was admitted January 3rd and discharged on January 9th. According to Joint Commission, this electronic record must be complete by:

Registration-Admission-Discharge-Transfer System (RADT)

This application creates a centralized database of patient demographic information and has replaced the paper master patient index in the virtual world.

patient monitoring system

monitors the patients levels, blood pressure, etc.

Flase. A record transitional template is a document that delineates the various sources of the component parts of the patient's record.

A clinical record template is a document that delineates the various sources of the component parts of the patient's record.

False. A group of characters, which can be numeric digits, letters, or a special character, forms a field.

A group of characters forms a file.

Character

A lowercase or an uppercase letter, numeric digit, or special character is also known as (a)

bar code scanner

An input device that reads a bar code and identifies a document as belonging to a specific patient.

central processing unit (CPU)

Controls the processing of information throughout a computer system and includes the control unit, arithmetic/logic unit, and primary storage unit.

health data

Health facts that are collected about a patient or group of patients that describe a health issue.

True

Health information management (HIM) professionals need to develop policies that facilitate a complete and accurate record.

True

Health information professionals have skills to assist facilities in the transition to the EHR.

indexed

Identification of scanned pages according to a unique identification number, making it unnecessary to scan documents for the same patient at the time; each scanned page is indexed so the complete patient record can be retrieved even if a patient's reports are scanned at different times.

character

Lowercase and uppercase letters, numeric digits, and special characters.

computer-based patient record (CPR)

Multidisciplinary and multi-enterprise software that has the ability to link patient information at different locations according to a unique patient identifier.

Sharing information

Regional Health Information Organizations (RHIOs) focus on what key function?

False. The equipment used to capture paper record images onto electronic storage media is called a scanner.

The equipment used to capture paper record images onto electronic storage media is called a portal.

False. The state law is the primary basis for the definition of the legal patient record.

The federal law is the primary basis for the definition of the legal patient record.

hardware

The physical equipment is used by a computer system, including the central processing unit, storage devices, input and output devices, and networking equipment.

Laboratory application

The physician orders UA and C/S. Which clinical application would correspond with this request?

Radiology application

The physician orders a KUB. Which clinical application would correspond with this request?

False. The type of application that includes order entry, identification of drug interactions, medical label printing, and administrative reports such as drug usage is known as a pharmacy application.

The type of application that includes order entry, identification of drug interactions, medical label printing, and administrative reports such as drug usage is known as a medical administration application.

storage device (memory device)

Used to save, retrieve, and use data, such as computer chips, CDs, DVDs, hard drives, and magnetic tape.

Longitudinal Patient Record

What type of record contains records from different episodes of care, providers, and facilities that are linked to form a view, over time, of a patient's health care encounters?

Computerized Medical Records

What was a 1970 - 1980 term to describe early medical record automation attempts?

indexed

When a page is _____, it means it is identified according to a unique identification number, which is commonly the patient's medical record number.