Allied CEHRS Module 1-5 FULL review

Medical record #

set of # used to ID patient

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 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 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 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

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 happens if the provider requests a referral?

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

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 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 is internal data?

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

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 do electronic signature pads do?

they capture patient signatures, records patient acknowledgments, consent for treatment, & patient responsibility for service charges. -eliminates the need for printing and reduces the risk of the document being found accidentally.

What do scanners do?

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

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 do cameras do?

capture clinical data, doc findings, & physical identification.

What do bar codes do?

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

What is hybrid record state?

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

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 is Electronic Medication Administration(eMAR)?

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

How are bigger health care systems inventory maintained?

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

How are smaller health care systems inventory maintained?

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

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 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

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

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

it stores images of diagnostic tests & interpretation of studies.

What does the Laboratory Info System(LIS) do?

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

What does the Radiology Info System(RIS) do?

transfers imaging orders & patient data to testing devices

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 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.

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

• history

• examination

• medical decision making

• counseling

• coordination of care

• nature of presenting problem

• time

What happens when charting is mismatched/incomplete?

it is FLAGGED

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 if there are errors on the EHR?

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

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 information is available in patient portals?

• appointments

• lab results

• summary of encounter doc (diagnosis, treatment, follow-up plans)

• financial data(charges on services by provider)

• diagnostic test orders & results

• consultations

• procedures

• 3rd party insurance payer

What may physical, speech, & occupational therapists do?

they may provide rehabilitation services & document in EHR.

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.

How are lab results transmitted?

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

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 captured during a test.

What do IT professionals enable?

interoperability & data exchange which prevents delays in treatments

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)

Where are alerts coordinated?

to include info stored in LIS & PMS

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 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

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.

What is the system designed for?

to verify identity & confirm coverage

• insurance copayments are collected

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 you put in the EHR if a patient dies?

patient has EXPIRED

What do you do when recording days off for providers?

record the vacation days as non-patient appointments

What can the electronic schedule ALWAYS allow?

to reschedule appointments

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

for initiating inventory of e-signature pads

What does cataloging images ensure?

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

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

it is moved to the ACCOUNTABILITY portion

Clinical templates

predesigned forms for capturing data specific to an organization's workflow & tasks that make documentation easier

What is the Clinical Decision Support System(CDSS)?

a program designed to prompt providers with clinical designs

What do clinical templates do?

• assist providers & other clinical staff w/ charge capture, billing & coding

• letters for patients who need to miss work

• light-duty restrictions

• school absence excuses

• report test results

• proof of physical exam

• reminder of late payments

• request consultations

What does the Health Information Exchange do?

• electronic reporting of lab results & imaging reports

• instant access to records from other facilities & organizations

• electronic prescriptions

• integration of clinical databases w/ the clinical decisions support system

• potential of a fully electronic revenue cycle

What does the health information exchange enable?

it enables a patient's medical records to follow them anywhere

• reduces duplication of services

• avoid unnecessary visits

• avoids medication errors & adverse interactions

• improve care coordination

What is included in a Protected Health Information(PHI)?

Health info that is specific to a patient

• name

• age

• sex

• address

• demographic info.

• account info.

• social status

• clinical status

When is disclosure of a PHI mandatory?

• when a patient or legally authorized representative requests it

• part of an investigation by the department of health & human services

What do patients have the right to?

• receive an explanation of an organization's privacy practices

• request restrictions on disclosure of specific info

• specify how they receive confidential communication

• inspect or obtain a copy of health record

• request amendment records they think are accurate

What type of information may an organization use or share individually w/o specific patient authorization?

Treatment(management of person's care)

• consultation between providers & referred to other specialties Payment(the exchange of info between insurance)

• companies, payers, & service providers in order to grant request & payment Health care operations(chart reviews & audits, quality improvement & staff competency programs, business planning & business management)

What does the Privacy rule also allow?

incidental disclosures

• hearing another patient's name in a waiting room public interest

• data on vaccines, communicable diseases, dangers to the public, law enforcement & workers compensation

what is the minimum necessary concept?

transmit only minimum amount of PHI necessary

What are safeguards?

security rule sets national standards for preventing inappropriate access to or transmission of PHI

• anytime a policy is charged, the old policy must be accessible for review for 6 yrs

What are examples of safeguards?

risk analysis & management -consists of looking at an organization's processes, identifying where & how much data could be accessed inappropriately & preventing it.

physical safeguards -limiting access to work areas & proper disposal & re-use of electronic media & devices

technical safeguards -password protection, a secure server w/ dual authentication systems & backup system that have copies (audit controls keep records of how much, when & by whom info is accessed & when encryption should be used)

• encrypted info cannot be used by unauthorized users

administrative safeguards -having designated employees responsible for security, training, staff education & having a system for evaluating effectiveness of security measures

policies & procedures -for security must be in writing & updated whenever there is change that affects EHR security

What is the purpose of Clinical Documentation?

clinical documentation(charting) forms a record of a patient's health status, health maintenance activities, treatments, interventions & effectiveness.....communicates to the patient and all providers included.

What is clinical documentation utilized for?

• research

• administration

• public health initiatives

• quality improvement

What are components of clinical documentation?

• history

• physical exam

• assessment

• treatment plan

• chief complaint

• subjective elements

• review of systems

• objective data

What are clinical documentation errors?

• omissions

• failure to complete documentation in an acceptable time frame

• improper use of abbreviations

• typographical errors

• assigning codes for a more or less complex encounter than performed(over/undercoding)

• incorrect documentation through use of cloned notes

what are cloned notes?

is a document that is copied and pasted from one patient encounter to another, can cause MISTAKES

Revenue Cycle

start of claim -> submission of claim -> management of claim -> collections & follow up -> payment & analytics

what does billing & reimbursement rely on?

accurate code assignment *the supporting are published by CMS

what are the 7 components of determining the level of component based on E&M codes?

• history

• examination

• medical decision making

• counseling

• coordination of care

• nature of presenting problem

• time required to complete visit

Chief complaint

the reason for encounter/visit ex: patient feels dizzy

• location of pain or symptoms

• quality (sharp, dull, burning)

• severity

• duration

• timing

• context

• modifying factors

• associated signs & symptoms OPQRST acronym

Review of Systems (ROS)

involves a provider asking specific questions about major body systems about symptoms

• comprehensive, ex: hospital admissions note, annual physical

• focused on systems affected by chief complaint *roster template has a drop-down when recording info in the EHR

What does the EHR template for ROS have?

• positive findings

• pertinent findings

• normal/negative findings

Subjective elements

summary of what the patient tells the clinic staff about history, family, family history, problems, concerns, symptoms & goals

past history

• medications

• allergies

• previous health problems/injuries

• surgeries

• prior hospitalization

• age appropriation immunization status

• age appropriation feeding/diet status

family history

• health status or cause of death of parents, siblings, & children

• specific diseases related to problems identified in chief complaint, HPI, or ROS

• diseases of family members which may be hereditary or place the patient at risk

social history

• martial status/living arrangements

• current employment

• occupational history

• use of drugs, alcohol, or tobacco

• level of education

• sexual history -other relevant social factors

What is also included in historical data?

history of present illness

• the HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present.

Objective data

anything that can be observed or measured by clinical staff -prior records, vital signs, test & imaging results, speech & behavior observation, physical examination findings, etc.

What is real time point of care (POC) data entry?

immediate documentation of all data obtained & events that occur in a patient encounter as they happen w/ the goal of having it complete by the end of the encounter

what do you need in order to achieve accurate, complete POC documentation?

• efficient system of data entry

• having all supporting info required for clinical decision making readily available Alternate has inaccuracy & increased omissions

what is syndromic surveillance?

public health surveillance to monitor real time diseases & outbreaks

what does a typical encounter look like?

1. the patient's demographic data is updated

2. vital signs are taken & documented

3. provider interviews the patient

4. examines the patient

5. new orders are entered

6. the patient is given educational materials

What does Point of Care (POC) charting do?

it reduces the time between providing care & documenting, which increases the likelihood the documentation is accurate, detailed & complete

Adopting POC documentation

• workflow

• physical environments

• adjustments & human factors engineering

What does Computer Provider Order Entry (CPOE) do?

electronic process by which providers give instructions for patient care in both in/out patient settings

what orders can be place through CPOE?

-medications -treatments -imaging -monitoring modalities -lab studies -consultations/referrals to other providers

Patient education

patients always have access to their notes, lab results/imaging through an online portal & a printed copy of their visit note & resources at the end of each visit

• also explains conditions, treatments, & medications uses CDC, AHA, and more for info

• it is presented in simplified terms for patient's sake

What can happen in a clinical decision support system (CDSS)?

-admission assessments in the inpatient setting prompt to ask about allergies -outpatient, vaccine reminders, reminds patient if any immunization are due

what happens within interoperability programs?

-it is incentive based -meeting specific measures results in a positive adjustment for reporting year, & negative adjustment for those who fail to meet requirements

What do patient encounters consist of?

history, physical exam, review of systems, diagnosis & treatment plan

• procedure notes: include a description of the procedure performed & documented

• the system enables members to create links to other parts of EHR: vital signs, flowsheet, lab/imaging results, meds, & problem lists....current vital signs, lab results, & other info can be imported directly into the note(procedure notes)

What does the EHR system often not allow?

users to create customized templates

When can patients begin entering info?

from a kiosk or online portal in a clinical setting

what to do when you're in doubt about the risk management form?

review any pertinent state & federal regulations/consult the organizations risk management form