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CEHRS Final Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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CEHRS Final Exam | Questions And Answers Latest {} A+ Graded | 100% Verified
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CEHRS Final Exam | Questions And Answers Latest {2024- 2025} A+ Graded | 100%Verified
Electronic Health Records - EHRs
Electronic Medical Records - EMRs
EHR technology - large integrated EHR systems and smaller, single-use EMR software.
Protected Health Information (PHI) - technological advancements have improved the options for the
storage and distaster recovery of important patient clinical and business information.
Health Insurance Portability and Accountability (HIPPA) - Privacy and guidelines for business associates.
Health Information Technology for Economic and Clinical Health - (HITECH) Act
American Recovery and Reinvestment Act of 2009 (ARRA) - introduced increased responsibilities and
greater punishments for improper management of PHI
Covered entities - hospitals, provider offices, and clinics, as well as their business associates which are
often known as third-party vendors, are responsible for proper handling of PHI and are accountable for
any breach of information or privacy.
Legacy information systems - In inpatient environments it is common to find many of these. They
predicate EHR implementation and represent a virality of vendors.
Data exchange standards most often referenced include the following. - 1. American National Standard
Institute (ANSI) Accredited Standards Committee x12 (ASC X12)
2. The American Society for Testing and Materials (ASTM)
3. Digital Imaging and Communications in Medicine (DICOM)
4. Health Level Seven (HL7)
,5. National Council for Prescription Drug Programs (NCPDP)
- different health information systems that wish to communicate with each other must adhere to the
standards set forth by these organizations.
Computerized Provider Order Entry (CPOE) - The provider inputs an admission order into the EHR
system using this
Patient Care Orders (PCO's) - after the provider enters the admission order they can order patients diets,
medications, tests including labs or imaging studies, & nursing orders.
The Joint Commission on the Accreditation of Health Care Organizations (Joint Commission) & Centers
for Medicare and Medicaid Services (CMS) - require that the patient record contains a current History
and Physical report ( H&P) within 24 hours of the patient admission.
History and Physical (H&P) - Report within 24 hours of the patients admission.
What is a medical record - An important business document, a medical record is used to support
treatment decisions, document services provided, and could also be used in a court of law for evidence
purposes. Electronic Medical Records (EMR) are computerized records of one physician's encounter with
a patient over time. The EMR reflects treatment of a patient by one physician. In contrast an Electronic
Health Records (EHR) reflects the data from all sources that have treated the individual. Personal Health
Records (PHR) are maintained and owned by the patient. The patient makes the decision whether to
share the contents with their physician. The contents of a health record vary depending on the setting.
Acute care, most refers to a hospital, treats patients with urgent problems that cannot be handled.
Ambulatory care refers to treatment without admission to hospital. Hospital records keep track of time-
limited episodes where doctor charts are reflective of the ongoing health of individuals.
Advantages of Electronic health records - Safety
Quality of Care
Efficiency
Cost Reduction
What are clinical standards - Clinical Standards are the rules or guidelines that are followed by different
components of the health care system when data is made, used, and shared on and between
, components. Clinical Standards software lowers the error rate of clinical data, and allows the
automation of routine and repetitive processes.
Clinical Standards are critical to providing the best possible patient care and they are necessary to
establishing a national health information network.
Clinical Standards include the following types of standards: Conceptual, Terminology, Document,
Messaging, Application, and Architecture Standards.
Types of Clinical Standards - Clinical vocabularies-set of common definitions for medical terms to ease
communication by decreasing ambiguity.
SNOMED-CT(Systemized Nomenclature of Medicine Clinical Terms)- Clinical vocabulary designed to
encompass all terms used in medicine.
LOINC (Logical Observation Identifiers Names and Codes)- terms and codes used for electronic exchange
of lab results and clinical observations.
UMLS (Unified Medical Language System)- Thesaurus database of medical terms.
HL7 (Health Level 7)-Messaging: specifically scheduling, medical record and imaging management,
patient administration, financial management, patient care, public health notification, Immunizations,
and observation reporting.
NCPDP (National Council for Prescription Drug Program)- retail pharmacy transactions.
DICOM (Digital Imaging and Communication in Medicine)- Image information to workstations.
accept assignment - the provider agrees to accept what the insurance company approves as payment in
full for the claim
assignment of benefits - reimbursement is directly sent from the payer to the provider
Civil Monetary Penalties Law (CNPL) - law passed by the federal government to prosecute cases of
Medicare fraud
co-payment - a cost-sharing requirement for the insured to pay a specific dollar amount at the time of
service
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