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EHR Final test

A medical nomenclature and knowledge base developed by Medicomp Systems Inc.
Code to classify mortality and morbidity. International Classification of Disease, 9th revision, Clinical Modification
Explain the difference between an EHR nomenclature and a billing code set.
EHR codes details and Billing Code Sets is patient details
Which screen do you use to set the reason for visit?
On the new encounter form
How do you enter vital signs?
Click the forms button in the tool bar then the vitals option
How do you load a list?
highlight the list wanted and press the load list button
Review of Systems
History of Present Illness
Head. Eyes. Ears. Nose.Throat
Upper Respiratory Infection
Describe how to record a test that was performed.
Select the test then go to prefix and select performed from the drop down list.
What Entry Details field is used with a finding to indicate a”possible” diagnosis?
select diagnosis then go to prefix and select possible
What month and year is the United States scheduled to begin using ICD-10?
October 2013
Describe the closed loof of medication administration.
Electronic prescription CPOE then sent to pharmacy
Compare the advantages of codified EHR data over scanned document data.
EHR is a larger variety of body systems and functions that can go from general to specific.
Name at least 3 things that are checked by a DUR alert system.
Underdosing, Overdosing and Allergic Reactions
List Size:
shrinks or expands the tree list based on diagnosis
adds prescription drugs to plan, orders meds
opens a window to find items more easily
marks no for symptoms patient does not have
Review of systems looks at parts affected by the chief complaint
adds more detail to the search
orders the test related to the encounter form
Where does the data that appears in the patient management tab come from?
the existing encounter form from previous visits
Why would clinicians use trending of lab results and what type of results can be graphed?
medication, current test results and physical changes over time; Numerical values
Describe the benefits of having patients entering their own symptoms and history.
the patient knows their history and can decribe their own symptoms better than someone else; primary source of past medical social history; can review history to be better prepared for appointment; primary source of the outcome of symptom awareness
Why are child immunizations important?
Immunizations slows down or stops disease outbreaks
List 3 ways that codified data in the EHR can be used to manage and prevent disease.
disease management, graphic analysis, interactive alerts
Describe a problem list and provide at least 2 reasons why clinicians use a problem list.
a problem list is an up-to-date list of diagnosis and conditions that affect a particular patients care. easy to see active problems for a patient, view the history of the problems
Describe how to create a flow sheet from a form.
while on the form tab with a form loaded, click on the button labeled “FS Form”
What does it mean to cite a finding and how would you do it from a flow sheet?
citing from previous exam notes means to bring a finding into the encounter usually as a follow-up from a previous visit. click the cite button on and then click on a single finding in one of the columns, or click the date at the top of the column
How does an E-visit differ from provider-to-patient emails?
E-visit is more secure
What are “evidence-based” guidelines?
“evidence-based” guidelines are ways to analyze scientific evidence from current research and studies to determine the effectiveness of preventative services.
Name at least 3 external sources of data for populating the EHR?
electronic lab orders and results, vital signs, ECG
What is a growth chart percentile?
curved lines representing what % of the reference population the individual would equal or exceed at a given size or age
List 4 components of the HIPAA Administrative Simplification Subsection.
transactions and code sets, uniform identifiers, privacy and security
Compare the difference between HIPAA consent and HIPAA authorization.
authorization requires the patient’s permission to disclose PHI; signed consent is optional
Does a provider need the patient’s consent to share PHI with an authorized government agency?
Name the covered entities under HIPAA.
healthcare providers, health insurance plans, and clearing houses
Name some of the advantages of PHR.
available wherever the patient is treated, PHR is secure and private and is owned and managed by the patient. Patients control who can access their records.
Give an example of a specialty that might use annotated drawings in an encounter note.
Opthalmology and Dermatology
How is the Internet changing healthcare?
People shop for doctors online, insurance companies provide online participating provider lists, physician specialty associations and state and local medical societies all offer websites that help patients locate a provider near them.
List 3 criteria of an electronic signature.
message integrity, non-repudiation, and user authentication
Name the key components of an E&M code.
history, examination, medical decision making
Where are “bullets” used in E&M calculation.
in the examination component. they refer to specific items in various body systems marked with a typographic character called a “bullet” in the CMS guidelines
information protected by the Security Rule
Electronic Signature standard
calculation for height/weight ratio
Procedure Code Set
three vaccines
enforces HIPAA Privacy Rule
element of a patient exam
method of internet security

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