EMR Chapter 2 Assessment

Robert Fitzsimmons is an administrator with the local hospital. His responsibilities include the maintenance and security of all of the automated systems that affect individual departments as well as the electronic health record. Mr. Fitzsimmons is a

health systems administrator.

Memorial Hospital is in the process of researching a new facility-wide electronic health record system. The _________blank would be responsible for assessing the budgeting process, funding, and monitoring the monetary aspects of the project.

chief financial officer

In a physician's practice, _________blank may be the title of the person who is responsible for the overall administrative management of the practice.

Office Administrator

The health information manager and the _________blank work closely to ensure a fully operational, secure electronic health record that meets the needs of all users within the facility?

Multiple Choice

Chief Information Officer

Until recent years, Registered Health Information Technicians, Registered Health Information Administrators, and Certified Health Data Analysts typically worked primarily in which type of facility?

hospitals

A zip code would be an example of _________blank data.

structured

An x-ray of the ankle was performed on Daniel Way on December 16. Dr. Eberly interpreted the x-ray and dictated his impression, which then became part of the hospital's electronic health record. This impression is _________blank data.

unstructured

The date of birth on a patient's record is _________blank data.

structured

The image above would be found in which format?

paper health record

A record that contains a person's health history, allergies, current complaints, past medical and surgical history, and a listing of current medications, but is not considered a legal health record is a/an

personal health record.

Entering data into a computer system is also known as _________blank data.

capturing

From which source is the image above taken?

electronic health record

When collecting data on a computer or retrieving data from a computer, the screen becomes the replacement for _________blank.

paper

How many surgeries has this patient undergone?

2

The patient has a heart rate of 98 and a blood pressure of 178/98. These are known as:

vital signs

The capturing of data about a patient begins at what point?

when the patient calls for an appointment or arrives at the hospital for care

Of the following, which is not a core function of the EHR as defined by the National Academies of Sciences, Engineering and Medicine (formerly the Institute of Medicine)?

filing of insurance claims

The _________blank allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information.

Electronic Health Record (EHR)

"A set of standards, services, and policies that enable the secure exchange of health information over the Internet" is known as

National Health Information Network.

In order to send and accept diagnosis codes using ICD-10-CM, which version of the HIPAA Code Set rule was effective as of January 1, 2012?

version 5010

The _________blank is a unique identifier that is used on insurance claims and identifies the healthcare provider or hospital/organization that has provided care to the patient.

NPI

A unique identifier that is required on claim forms and identifies the care provider or group practice submitting the claim is the

National Provider Identifier number.

The hospital equivalent to practice management software used in the physician's practice is known as

Registration, Admission, Discharge, Transfer System (aka Admission, Discharge, Transfer System).

John Smith was admitted to Memorial Hospital on June 6 and died while in the hospital, on June 10. The action taken on June 10 was a/an

discharge.

In a hospital setting, when the patient presents for care he/she is

registered