Electronic Health Records

Interoperability

The ability of electronic systems to share information in compatible formats

Chief Complaint

The patient’s stated primary reason for seeking treatment

Ledger

Screen that contains the amount owed and other billing details

CPOE

An EHR function that facilitates automated prescribing

Copayment

A fixed sum of money usually paid at the time medical services are rendered

HIPAA 5010

An electronic format that speeds the claims process for physicians and suppliers

Day sheet

A register of business transactions for a single day

Electronic transcription

Data entry using structured data entry or voice recognition

Structured data entry

Documentation that utilizes drop-down menus, radio buttons, and sentence builders

Practice management software

Used for administrative tasks such as appointment scheduling and billing

An audit is performed by the office manager to investigate whether appropriate employees have viewed the contents of a high-profile patient’s chart

True

The medical record contains legal documents but is not itself a legal document

False

The medical assistant’s typical duties will be modified with the implementation of the EHR

True

Clinical decision support tools are effective only if the provider chooses to use them

True

An EHR system can help the provider and medical staff plan and coordinate care for a patient with a chronic illness

True

Automated sentence building is a means of electronic transcription

False

Reduced productivity is to be expected for a period of time during the conversion to an EHR system

True

Communication among various treating healthcare providers, pharmacies, and allied healthcare workers will be limited until EHR interoperability has been achieved

True

It is possible for individuals to penetrate EHR systems despite security precautions

True

EHR systems make it unnecessary for office staff to be familiar with medical terminology

False

Most EHR systems hold the ability to handle clinical and administrative functions without purchasing separate management software

True

Professional organizations continuing education for the core skills of their discipline and do not have any opportunities for learning about the EHR

False

The amount of time records must be kept in storage by a medical office

Retention Period

A secondary, related set of options displayed by holding the cursor over an entry on the main menu by clicking to expand a list

Check box

A specialized graphic element that toggles on and off and is used when only one response is appropriate because two of these buttons can’t be depressed at the same time

Radio Button

Space allocated on a form for specific numeric or text data

Field

Used to describe an established patient who currently sees the physician

Active Patient

Most medical assistants are employed in inpatient settings

False

SCMO does not include the ability to create patient letters because it is easier to store these documents outside of the patient record

False

Unfortunately no two systems are the same, so knowing how to use one EHR will be little help in learning to use another

False

SCMO is used to document clinical data and does not function as a practice management software (PMS) system

False

The user must first perform a patient search before entering a new patient record

True

When creating a new patient account, the user must randomly select a number to be the medical record number

False

SCMO allows the user to enter up to three insurance carriers

False

To submit an assignment the user should perform the EHR activity and answer quiz questions

True

Another name for a Patient Registry is a master patient index

True

Closed patient records are the records of patients who have not been seen in the past 6 months

False

The New Patient screen contains a patient’s contact information and demographics

True

Information from the internet is not reliable enough to use for patient education

True

Confidentiality

The patient’s right and expectation that individually identifiable health information will be kept private

Disclosure

Giving access to, releasing, or transferring health information to another person or identity

Protected Health Information (PHI)

Individually identifiable health information that is stored, maintained, or transmitted electronically

Covered Entities

Healthcare providers, health plans, and healthcare clearing houses that transmit claims electronically

Consumer Reporting Agency

An agency that sells or cooperatively exchanges consumer information and history in areas such as credit and healthcare

Anonymity

The patient’s right to have private health data collected in such a way that it can never be linked to him or her

Password

A character used to prevent unauthorized access to patient information contained in secure electronic files

Authentication

The process of determining whether the person attempting to access a given network or EHR system is authorized to do so

Laws

Formal, enforceable rules and policies based on community standards of conduct.

Privacy

The patient’s freedom to determine when, how much, and under what circumstances his or her medical information may be disclosed

Minimum Necessary Standard

A key provision of the HIPAA Privacy Rule requiring that disclosures include no more than the amount of information necessary to accomplish a given purpose

Consent

Permission given to a covered entity for uses and disclosures of protected health information for treatment, payment, and healthcare operations

Secondary Use

A use of health information for a business activity or other purpose that is not directly related to patient care

Individually Identifiable Health Information (IIHI)

Health information that clearly identifies an individual patient or could reasonably be used to identify the patient

Ethics

Rules and standards of conduct that govern professional behavior and arise form or shared understanding of morality

When a patient requests confidentiality regarding particular test results or diagnoses, the provider is obligated to hold that information in confidence

True

Covered entities - healthcare providers, health plans, and healthcare clearinghouses - are subject to the HIPAA privacy rule

True

The HIPAA Security Rule outlines the administrative, physical, and technologic measures covered entities must take in order to implement and comply with the HIPAA Privacy Rule

True

HITECH requires that physician offices begin implementing an EHR immediately

False

A computer can verify that a password is valid but cannot authenticate that the person using the password is authorized to do so

True

A screensaver is used to limit the view of patient information on a computer screen while the user is away from his or her desk

True

If erroneous information is found in a file, it can be removed at the patient’s request

False

HIPAA prohibits financial institutions from obtaining medical information

True

A healthcare professional may speak to a patient's family or friends about the patient's general condition and location as long as the patient doesn't object or, if the patient is incapacitated, it can reasonably be inferred that he or she wouldn't object

True

Waiting Room

The first stop in a patient's path through the medical office.

Secure Email

A system capable of transmitting an encrypted message and storing it in coded format until it is retrieved by the recipient via a secure web link.

Retention

The period of time patient records must, by law, be maintained by the medical office.

Show Rate

The percentage of patients in a practice who arrive for appointments as scheduled or call in advance to cancel or reschedule.

Double Booking

Giving two or more patients the same appointment time with the same provider.

Purging

The process of separating inactive patient health records from active ones.

Telephone Etiquette

A polite, helpful response and respectful manner toward callers.

No Show

A patient who makes and appointment and neither shows up nor calls to cancel.

Appointment Slot

A period of time reserved for a patient to see a healthcare provider.

Views

Different ways of displaying the same or similar information on a computer screen, usually with increasing or decreasing detail.

Secure Fax

A fax transmission sent via secure email.

Encryption Technology

A system that keeps data secure by converting it into an unreadable code during transmission and then un-encrypting the information when it reaches the recipient.

Patient Flow

A product of accurately estimated patient volume, a consistent provider pace, and efficient scheduling practices.

You should avoid apologizing to patient because doing so constitutes an admission that the practice has made a mistake.

False

The HIPAA Privacy Rule allows medical practices and other covered entities to disclose some healthcare information via email, fax, or phone without specific patient authorization, provided reasonable precautions are taken to protect privacy.

True

Use of a script is a helpful way for patients to understand that the physician has reserved specific time for them.

False

HIPAA-compliant secure email services may also offer web hosting services, spam filtering, virus protection, and related accessories, such as shared calendars and address books.

True

Always set up the patient EHR account using the name listed on the insurance or ID card.

True

Several users can access the electronic appointment book at once.

True

EHR users should find the scheduling view that works best for their office and ask the administrator to program it in permanently.

False

Appointment slots should be blocked out fro trips, holiday, or out-of-office time using the Block Appointment type.

True

Acute Condition

An episodic illness or injury of limited duration that responds well to treatment.

Medication Reconciliation

The process of comparing the medication list in the patient's EHR with the patient's self-report.

Review of Systems (ROS)

An organized inventory of each organ system.

Subjective

Perceived only by the patient and not evident to or measurable by the clinician.

Objective

Readily seen, perceived, or measured by the clinician.

Anthropometric Measurements

The height, weight, and size of the human body.

High Alert Medication

A medication that poses a heightened risk of injury or death when improperly administered.

E-Visit

A physician consultation with an established patient using a secure Internet service.

Chief Complaint

A brief statement of the problem, condition, or symptoms that prompted the patient to seek medical care.

History of Present Illness (HPI)

The duration, location, severity, context, associated signs and symptoms, quality, and modifying factors related to a patient's illness.

Chronic Condition

A prolonged illness that requires periodic follow-up.

Patient instructions should be performed in a well-lighted area with limited distractions.

True

Speech recognition software can distinguish one voice from another.

True

E-visits are illegal in most states.

False

Physicians using the EHR must use a structured method of data entry.

False

A medication reconciliation should be performed when a patient is removed from the operating room to the recovery room.

True