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NHA Study Guide 2023 EHRS questions and answers graded A+
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NHA Study Guide 2023 EHRS EXAM
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NHA Study Guide 2023 EHRSPeripheral devices: - ANSWERbar code scanners, cameras, printers, signature pads
etc
CPOE Computerized Provider Order Entry - ANSWERUse of a computer system to
enter and process prescriptions and treatments at the point of care
Optical Character Recognition software: - ANSWERused to find text within the scanned
document which is then stored within the image in the system
eMAR Electronic Medication Administration Record - ANSWERAn electronic record
containing a patient's prescribed medications, administration times, and who
administered it
Helpful information about EHR technology - ANSWERSoftware title, version, publisher,
date acquired, number of pieces installed, location
Picture Archiving and communication system PACS - ANSWERStore images of
diagnostic tests and interpretations of studies
Radiology Information System - ANSWERTransfer imaging orders and patient data to
testing devices
Practice Management System PMS - ANSWERManage revenue cycle processes
Laboratory Information System - ANSWERReceive pathology orders and transmit
results from the analyzer to the EHR
7 Components of Evaluation and Management - ANSWERHistory, examination, medical
decision making, counseling, coordination of care, nature of presenting problem, time
Personal Health Record PHR - ANSWERPatient portal where they can access their
medical record
Clinical Decision Support System CDSS - ANSWERA program designed to prompt
providers with clinical decisions
Covered Entity - ANSWERHealth plans, health care clearinghouses, and health care
providers
, HIPAA says PHI is all of these since they identify and individual - ANSWERName, age,
sex, address, demographic info, account info, social status, clinical status
HIPAA does not apply to - ANSWERDe-identified info used for marketing, staffing
projections, or supply chain activities
2 Situations when disclosure of PHI is mandatory - ANSWERWhen a patient or legally
authorized rep requests it, or as part of an investigation by the dept of health and
human services
Patients have a right to - ANSWERReceive an explanation of an org's privacy practices,
request restrictions on disclosure of specific info, specify how they receive confidential
communications, inspect or obtain a copy of their health record, request amendment of
records they think are inaccurate
An org may use or share PHI without authorization for the purposes of -
ANSWERTreatment, payment or health care operations
The Privacy Rule allows for - ANSWERDisclosures that are incidental, in the public
interest, or use of limited data
Incidental disclosure - ANSWERMinor ones that occur during legitimate use of info even
when when reasonable security measures are in place
Public Interest - ANSWERIncludes data on vaccines, communicable diseases, dangers
to the public, law enforcement, and workers' compensation
Minimum Necessary Concept - ANSWERTransmit only the least info you can to
complete the task at hand
Risk analysis and management - ANSWERConsists of looking at an organization's
processes and identifying where and how much data Ould be accessed inappropriately
and taking steps to prevent it
Common documentation errors - ANSWEROmissions, 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 before
(overcooking and undercoding), Incorrect documentation though use of cloned notes
Cloning - ANSWERA cloned note is documentation that a provider copied from a prior
visit (incorrect information may stay from prior notes if not carefully updated)
The History component is made up of these elements - ANSWERChief complaint,
history of present illness, review of systems, past history, family history, social history
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