Module 1 - Non-clinical operations

What do cameras do?

capture clinical data, doc findings, & physical identification.

What is external data?

data that originate outside the organization/office for which the research is being done. - directing info into patient's electronic record helps create a complete record for the patient. Includes: digital images, lab results, etc

What does cataloging images ensure?

ensures that a digital image imported from a fax machine is linked to EHR

What would the Universal Medical Device Nomenclature (UMDN) be helpful for?

for initiating inventory of e-signature pads

Where are info in the billing system generated from?

from the time of registration with: - patient demographic data - insurance data - reason for the visit

What to do when entering outpatient documentation for a new patient?

front office staff obtains info & creates an accounts - once info is electronically verified, a notification is sent and the patient is ready to see the provider.

What do scanners do?

integrate paper docs into EHR systems by scanning into images & uploading, prevents fragmentation of patient's record.

What do IT professionals enable?

interoperability & data exchange which prevents delays in treatments

What is the Health Info Management (HIM) Department?

it assesses a chart to ID discrepancies or missing info that can delay reimbursement for services or violate public policies

What happens when charting is mismatched/incomplete?

it is FLAGGED

How are lab results transmitted?

it is batched-processed by entering info into an automated instrument when evaluation is complete.

Where does an EHR specialist move hardware & media containing protected info?

it is moved to the ACCOUNTABILITY portion

What is the Practice Management Software(PMS)?

it keeps records of appointments, manages appointments, & completes registration. - ALSO manages revenue cycle - some offices start workflow w/ patient-centered data where the patient logs in & populates preregistration info. *PMS has everything recorded into the EHR

What is the Personal Health Record (PHR)?

it promotes patient engagement in managing their health & conditions *are commonly used for established patients & regular, noncomplex medical consultations you can: - conduct virtual visits - request appointments - ask questions

What does the Laboratory Info System(LIS) do?

it receives pathology orders & transmits results from the analyzer to the EHR.

What does Picture Archiving & Communication System (PACS) do?

it stores images of diagnostic tests & interpretation of studies.

What does HIPAA do in inventory management?

maintain accurate record of devices & software observes the physical security component of HIPAA: - use added security, ex: 2 factor authentication - install encryption - install security software ex: antivirus program - maintain physical control of device - VPN(virtual private network) - disable file-sharing application - only download from trusted devices

What to do with returning patients?

make sure to: - verify ID - compare patient's scanned insurance copy to current to verify continuity & name this prevents errors & delays

What to do with new patients?

make sure to: - verify ID w/ government-issued ID - verify the name on the insurance - scan insurance card into the system

What do you put in the EHR if a patient dies?

patient has EXPIRED

What do you do when in an ambulatory surgery setting when encountering documentation?

patient info is used to generate wristbands & labels for ID % display for health info

What do you do when recording days off for providers?

record the vacation days as non-patient appointments

What is internal data?

recorded by providers during an encounter Includes: financial info entered during scheduling & patient registration to enable reimbursement for services

Medical record #

set of # used to ID patient

What do bar codes do?

sets the standard for patient ID, prevents medical mistakes & makes charting easier.

How are smaller health care systems inventory maintained?

software & hardware are tracked by a consulting firm, office manage & EHR specialist

What to do when entering outpatient documentation for an established patient?

staff searches for record -> verifies personal data -> review + update insurance -> NPP(Notice of Privacy Practice) & other paperwork

How does the EHR transfer info?

the EHR automatically transfers info to the billing software OR PMS where the billing staff reviews & post charges in order to avoid discrepancies.

How are bigger health care systems inventory maintained?

the IT department manages inventory of software & hardware assets *maintaining inventory is important for record-keeping

What is recorded in the electronic superbill?

the personal data, financial data, diagnosis, & procedure codes are recorded to populate the charge entry form in the billing system

What if there are errors on the EHR?

the provider receives a MESSAGE to correct it *complete & accurate doc. are essential

What does Evaluation & Management(E&M) do?

these codes are used by providers to bill for services based on assessment findings documented in the visit note.

How are test results transmitted?

they are transmitted from LIS(interfaces w/ EHR system to deliver results to the patient's record) into patient's record to enable view to multiple providers when needed.

What do electronic signature pads do?

they capture patient signatures, records patient acknowledgements, consent for treatment, & patient responsibility for service charges.

What may physical, speech, & occupational therapists do?

they may provide rehabilitation services & document in EHR.

Where are alerts coordinated?

to include info stored in LIS & PMS

What can the electronic schedule ALWAYS allow?

to reschedule appointments

What is the system designed for?

to verify identity & confirm coverage - insurance copayments are collected

What does the Radiology Info System(RIS) do?

transfers imaging orders & patient data to testing devices

What is Computerized Provider Order Entry(CPOE)?

use of computer system to enter & process prescription & treatments at the point of care(POC). - enables the validation of ID to match the prescription w/ the patient.

What do fax machines do?

used to send & receive patient info standard fax -> feed doc into machine -> dial # -> sent eFax -> doc sent directly from computer to destination fax

What information is available in patient portals?

- appointments - lab results - summary of encounter doc - financial data(charges on services by provider) - diagnostic test orders & results - consultations - procedures - 3rd party insurance payer

What purpose does Billing & Coding serve?

- discrepancies in billing are identified in PMS (small clinics/offices use billing programs, larger & hospitals use a separate billing software) - billing software has error checking abilities that promote efficient processing of claims & lower the likelihood of denied reimbursement claims

What are the components of Evaluation & Management(E&M) ?

- history - examination - medical decision making - counseling - coordination of care - nature of presenting problem - time

What is on the Joint Commissions DO NOT USE list?

DO NOT USE: U, u IU Q.D/Q.oD X.0mg/.X Ms/MSO4 INSTEAD USE: unit international unit daily, every other day X mg/0.Xmg Morphine sulfate

What do hospitals that have an RIS commonly use?

PACS, to store & report results of diagnostic testing - electronic orders entered by providers in clinics are transmitted to RIS & patient images are captures during a test.

What is Assignment of Benefits?

Patient's authorization(signature) to allow health insurance payment to be made directly to the provider of insurance - reimbursement is sent directly from payer to provider

What does the provider enter to represent the treatment given or provided?

a Current Procedural Terminology (CPT)

What do organizations with CPOE systems usually have?

a Pharmacy Info System(PIS) component - the medication has a bar code that the nurse scans for accuracy - patient's wrist band is scanned to match the info w/ the electronic medication administration record(eMAR)

What is the Notice of privacy practice ( NPP)?

a doc that is required by law to inform a patient how the organization will use their health care info. - disclose patient's rights - given to patients at their first visit to a doctor's office or pharmacy - Explains how patient PHIs may be used

What is an advance directive?

a legal doc that contains info about a patient's treatment choices when they are unable to make decisions.

What is hybrid record state?

a system that uses both paper & electronic based processing for documentation of health information

What happens if the provider requests a referral?

a template can be used to enter the info for the referred provider to view.

What is Electronic Medication Administration(eMAR)?

an electronic record containing a patient's prescribed meds, administration times, & who administrated it.

How does inpatient admission begin?

begins w/ recording demographic data & identifying the patient as an active recipient. Admitting a patient: - emergency department (ED) or surgery department - after an office visit - transferred from another facility