documentation modules

recommendation sbar

-What do you want the patient/prescriber to do? -What action do you propose? -What do you need?

Background (SBAR)

-what is relevant to the problem? -summary of background -relevant information only -may include: patient's diagnosis, prescribing physician, date, dosage strength, dosage form, & labs

In what year did Dr. Lawrence Reed introduce the concept of computerized medical records? 1955 1960 1975 1980

1960

The Electronic Medical Records Mandate states that public and private healthcare providers must adopt and demonstrate "meaningful use" of electronic medical records by ____________. 2014 2015 2016 2020

2014

HITECH has updated some of the HIPAA guidelines to strengthen civil and criminal enforcement of its rules, and now has ____ categories of violations, and ____corresponding tiers of penalties. 3; 2 3: 3 4; 4 4; 6

4/4

Since the enactment of HITECH, over _________ jobs have been created to implement the Informatics project, with estimates 20% higher by 2018. 50,000 100,000 150,000 200,000

50k

Which of the following is a benefit of electronic documentation? Documentation can be done at the patient bedside in real time All entries are legible, and not subject to interpretation Data is available to everyone who needs it All of the above

All of the above

Which of the following will help ensure computer-related patient privacy? Having all computers password protected Monitoring all data searches Logging off when you have finished your entries All of the above

All of the above

HITECH has changed HIPAA regulations to stipulate that violations that proceed to court involving less than 500 people are now cases brought by the _____________. Individuals involved Local prosecutors Attorneys General Department of Health and Human Services

Attorneys General

What went into effect in 2001 to ensure that an individual's health information is properly protected and that privacy is always maintained? HITECH HIPAA Institute of Medicine Joint Commission

HIPAA

Which of the following was part of the federal government's American Recovery and Reinvestment Act of 2009? HITECH HIPAA Institute of Medicine Joint Commission

HITECH

In 1991, what entity published a report that detailed a vision for the creation of electronic medical records in the United States? The Joint Commission HIPAA Institute of Medicine HITECH

Institute of Medicine

According to HIPAA regulations, patient information may be released _____________. When patient injuries are associated with criminal activities When the patient tests positive for a sexually transmitted disease When a patient is verbally abusive to medical staff When cause of death is certified by a coroner

When patient injuries are associated with criminal activities

To maintain patient privacy, a hospital may release medical information about a patient as long as the patient's name is withheld. True False

false

In the healthcare industry conversion from paper patient records to computer-based medical records has created a new academic field of study called __________. Medi-IT Informatics CompuMed None of the above

informatics

Situation (SBAR)

provide a brief description of pertinent patient variables, demographics, clinical diagnosis, and location

Unlicensed individuals who can enter information into the electronic medical record are known as ______________. Medical assistants Stenographers Scribes None of the above

scribes

Assessment SBAR

state pertinent assessment findings obtained with interpretation of data

One of the benefits of electronic, or computer-based, documentation is that it allows you to utilize a problem-solving approach to patient care. True False

true