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HCA 115 Final
Define EHR - ANSWER Electronic Health records is held by more than one organization. Define EMR - ANSWER Electronic Medical Records is held by one organization. Family and personal history includes documentation of each patient encounter, phonecalls and refills. (T/F) - ANSWER True
When is editing and proofreading done in the writing process: - ANSWER After it hasbeen written the first time.
How do you ensure effective writing: - ANSWER Active voice, proofreading, being politeand courteous.
A face sheet contains what type of information: - ANSWER demographics Goals of meaningful use: - ANSWER Improve health outcomes, increased efficiency,maintaining security of PHI
HIPAA stands for: - ANSWER Health Insurance Portability and Accountability Act How do you correct an electronic record: - ANSWER addendum Following meaningful use will lead to: - ANSWER Better clinical outcomes.
ANS Purpose of meaningful use Engage patients and family, maintain privacy andsecurity and improve care coordination
Billing and coding is administrative and patient vital signs is: ANS clinical Reassure patients of the confidentiality and security of their electronic records by ANSAllowing them to view their electronic record
Patients form an opinion about the office based on: ANS Professional documents Electronic health records must be treated with care and attention to detail because theyare: - ANSWER Legal documents
Correspondence must be: - ANSWER Clear and concise Annotating: - ANSWER Underline and highlight key points Some of the disadvantages of electronic health records: - ANSWER Cost, training, andupgrades
Examples of proper nouns: - ANSWER Days of the week, names of organizations,copyrighted trademarks
Name for federal law described as HIPAA on steroids: ANSWER HITECH Act Medical documentation includes: ANSWER Accuracy of dates, spelling and grammarcheck, and clarity
A face sheet includes SOAP notes, allergy History or addresses and phone numbersAddress and phone
Maintaining security of PHI and increased efficiency and goals for working withelectronic health records and what other reason Improved health outcomes3 multiple choice options
Adding an addendum is the best way to make a correction to an EHRTrue
Example of Demographic InformationDOB, Name, Address
Clinical components of a record includes all butBilling Codes 3 multiple choice options
Allowing patients to view their electronic health records is the way to reassure patientsof the security and confidentiality of their EHR True Quick impressions of an office include EMR
Not paying attention to detail is a way to handle professional documents and EHS False Which one supports the affordable care act and results in better clinical outcomes Meaningful Use Compliance Clear and what else should be a part of professional medical correspondences Concise Is annotating part of proofreading No
Staff training and what else is a disadvantage of electronic health recordsSystem and software upgrades
Copyrighted tradenames, days of the week, and names of organizations are consideredproper nouns and should be Capitalized The H in HITECH stands for_____ and is known as "HIPPAA" on Steroids/ Health It is okay to use slang in medical documents False Improving care coordination, maintaining privacy and security, and engaging patientsand families is all part of
