NHA CEHRS EXAM NEWEST ACTUAL EXAM COMPLETE
220 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY GRADED A
1. Electronic Health Record (EHR): computerized lifelong record health care
record w/ data from all sources
technology that intertwines health info from a variety of sources
every encounter an ind has w/ the health care system is documented (labs,
scripts, ER visits, etc...)
2. New position created by EHR: *Clinical Analyst *Health Information
Technician
* Records and info coordinator
3. What setting may a CHERS work?: * Dr office labs * Ref Labs * Urgent Care
Centers * Nursing Home Facilities * Wellness Clinics * Hospitals
4. Why were chances in technology made?: from realization that medical
records were not meeting the needs of dr's & pt's. Increase in errors, rising
health care costs and missing link in a pt's coordination of care.
5. Medical Errors: -among most common causes of death, occur b/c:
*Lost medical records
*Miscommunicated pt request/messages
*Unreadable info due to poor handwriting
*Mislabeled lab specimens many of these errors could be overcome if info
tech were applied throughout healthcare system.
6. What potential does HIT have?: improve the quality of care and possibly
reduce the number of deaths attributed to medical errors
7. What was HIPPA designed for?: enacted in 1996, designed to protect pt's
private health info, ensure health care coverage when workers change or lose
their jobs, and uncover fraud and abuse in health care systems.
8. HIPPA requires the use of electronic rather than paper ins claims?: True
9. Standards: commonly agreed upon specifications, are what helped establish
the requirements necessary for agencies to follow
10. When did Pres Bush recommend the use of Health Information
Technology (HIT)? What was the goal? Who was established to meet
this goal?: In 2004, set 10 yr goal for all americans to be using EHR's, and
, established the OFFICE OF NATIONAL COORDINATION FOR HEALTH
INFORMATION (ONCHIT) to meet this goal.
11. HITSP?: department/organ that identified standards for exchange of health
info
12. CCHIT?: developed certification criteria for EHR software
13. What does the Nationwide Health Information Network (NHIN) provide?:
links medical records across the country
14. What 8 core functions does the Institute of Medicine suggest an EHR
should include?: 1) Health Info and data elements
2) Results Management
3) Order Management
4) Decision Support
5) Electronic communications and connectivity
6) Patient Support
7) Administrative Processes
8) Reporting and population management
15. Medical Record: an important business document used to support
treatment decisions documents services provided
could also be used in court of law for evidence purposes
16. Electronic Medical Record (EMR): computerized records of one dr's
encounter w/ a pt over time including medical history, diagnosis, treatment and
prognosis
17. What is the contrast between EMR's and EHR's?: EMR's reflect
treatment of a pt by one dr as EHR reflects data from ALL sources that have
treated and ind 18. Personal Health Record (PHR): maintained & owned by the
pt, pt makes decisions whether to share contents w/ their dr.
19. Acute Care: most often refers to a hospital, treats pt's w/ urgent problems
that cannot be handled in another setting (hospital records keep track of
time-limited episodes where dr charts reflect the ongoing health of ind)
***Inpatient treatment***
20. Ambulatory Care: refers to treatment w/o admission to hospital
21. What are the advantages of EHR's?: *Safety *Quality of Care *Efficiency
*Cost
Reduction
22. Will the decision of going completely electronic have a huge impact on
pt efficiency?: Yes
, 23. What is a Total Conversion?: method of converting medical records all at
one from paper to electronic, may be costly, but it allows all pt data to be
converted at once while office can still service pt's ***outsourced to an
external company*** 24. What is Incremental Conversion?: gradual
change to electronic records. Advantage of this type of change are lower
cost and a smoother transition due to less of an impact on the office.
Disadvantages are that paper still needs to be used and not all pt data is
available. ***usually begins w/ pt's w/ scheduled appt****
25. What is Hybrid Conversion?: using a combination of paper and electron
form of data. No matter what form is used dr still need to enter progress
notes (most dr choose dictation/transcription process) ***some may be
outsourced, others in house**
26. What are clinical templates and what do they allow?: structured form
(progress notes) that allows dr's to document pt encounters into an EHR,
once it is entered it must be INTEROPERABLE: must be able to exchange
info and use it in a meaningful way, therefore clinical standards are important
to the details of pt info
27. Clinical Standards: -ensure consistency, reliability and safety
28. Types of Clinical Standards: -CLINICAL VOCABULARIES- set of common
definitions for medical terms, they ease communications by decreasing
ambiguity -SNOMED-CT- clinical vocabulary designed to encompass all
terms used in medicine
-LOINC- terms and codes used for electronic exchange of lab results and clinical
observations
-UMLS- thesaurus database of medical terms
29. What are CLASSIFICATION SYSTEMS?: they organize terms into
categories for easy retrieval, they are used for billing and reimbursement,
statistical reporting and admin functions
30. ICD-9 and ICD-10: International Classification of Disease-standard
developed by World Health Organization (WHO) contains diagnosis codes
that are used in all health care settings.
31. ICD-9-CM: DIAGNOSIS USAGE: Inpatient & Outpatient
*Number of characters: 3-5 alphanumeric
*Number of Codes: 13,000
PROCEDURE USAGE: Inpatient*
*# of characters: 3-4 numeric
*# of codes 4,000
32. ICD-10-CM: DIAGNOSIS USAGE: inpatient & outpatient
*# of characters: 3-7 alphanumeric
220 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY GRADED A
1. Electronic Health Record (EHR): computerized lifelong record health care
record w/ data from all sources
technology that intertwines health info from a variety of sources
every encounter an ind has w/ the health care system is documented (labs,
scripts, ER visits, etc...)
2. New position created by EHR: *Clinical Analyst *Health Information
Technician
* Records and info coordinator
3. What setting may a CHERS work?: * Dr office labs * Ref Labs * Urgent Care
Centers * Nursing Home Facilities * Wellness Clinics * Hospitals
4. Why were chances in technology made?: from realization that medical
records were not meeting the needs of dr's & pt's. Increase in errors, rising
health care costs and missing link in a pt's coordination of care.
5. Medical Errors: -among most common causes of death, occur b/c:
*Lost medical records
*Miscommunicated pt request/messages
*Unreadable info due to poor handwriting
*Mislabeled lab specimens many of these errors could be overcome if info
tech were applied throughout healthcare system.
6. What potential does HIT have?: improve the quality of care and possibly
reduce the number of deaths attributed to medical errors
7. What was HIPPA designed for?: enacted in 1996, designed to protect pt's
private health info, ensure health care coverage when workers change or lose
their jobs, and uncover fraud and abuse in health care systems.
8. HIPPA requires the use of electronic rather than paper ins claims?: True
9. Standards: commonly agreed upon specifications, are what helped establish
the requirements necessary for agencies to follow
10. When did Pres Bush recommend the use of Health Information
Technology (HIT)? What was the goal? Who was established to meet
this goal?: In 2004, set 10 yr goal for all americans to be using EHR's, and
, established the OFFICE OF NATIONAL COORDINATION FOR HEALTH
INFORMATION (ONCHIT) to meet this goal.
11. HITSP?: department/organ that identified standards for exchange of health
info
12. CCHIT?: developed certification criteria for EHR software
13. What does the Nationwide Health Information Network (NHIN) provide?:
links medical records across the country
14. What 8 core functions does the Institute of Medicine suggest an EHR
should include?: 1) Health Info and data elements
2) Results Management
3) Order Management
4) Decision Support
5) Electronic communications and connectivity
6) Patient Support
7) Administrative Processes
8) Reporting and population management
15. Medical Record: an important business document used to support
treatment decisions documents services provided
could also be used in court of law for evidence purposes
16. Electronic Medical Record (EMR): computerized records of one dr's
encounter w/ a pt over time including medical history, diagnosis, treatment and
prognosis
17. What is the contrast between EMR's and EHR's?: EMR's reflect
treatment of a pt by one dr as EHR reflects data from ALL sources that have
treated and ind 18. Personal Health Record (PHR): maintained & owned by the
pt, pt makes decisions whether to share contents w/ their dr.
19. Acute Care: most often refers to a hospital, treats pt's w/ urgent problems
that cannot be handled in another setting (hospital records keep track of
time-limited episodes where dr charts reflect the ongoing health of ind)
***Inpatient treatment***
20. Ambulatory Care: refers to treatment w/o admission to hospital
21. What are the advantages of EHR's?: *Safety *Quality of Care *Efficiency
*Cost
Reduction
22. Will the decision of going completely electronic have a huge impact on
pt efficiency?: Yes
, 23. What is a Total Conversion?: method of converting medical records all at
one from paper to electronic, may be costly, but it allows all pt data to be
converted at once while office can still service pt's ***outsourced to an
external company*** 24. What is Incremental Conversion?: gradual
change to electronic records. Advantage of this type of change are lower
cost and a smoother transition due to less of an impact on the office.
Disadvantages are that paper still needs to be used and not all pt data is
available. ***usually begins w/ pt's w/ scheduled appt****
25. What is Hybrid Conversion?: using a combination of paper and electron
form of data. No matter what form is used dr still need to enter progress
notes (most dr choose dictation/transcription process) ***some may be
outsourced, others in house**
26. What are clinical templates and what do they allow?: structured form
(progress notes) that allows dr's to document pt encounters into an EHR,
once it is entered it must be INTEROPERABLE: must be able to exchange
info and use it in a meaningful way, therefore clinical standards are important
to the details of pt info
27. Clinical Standards: -ensure consistency, reliability and safety
28. Types of Clinical Standards: -CLINICAL VOCABULARIES- set of common
definitions for medical terms, they ease communications by decreasing
ambiguity -SNOMED-CT- clinical vocabulary designed to encompass all
terms used in medicine
-LOINC- terms and codes used for electronic exchange of lab results and clinical
observations
-UMLS- thesaurus database of medical terms
29. What are CLASSIFICATION SYSTEMS?: they organize terms into
categories for easy retrieval, they are used for billing and reimbursement,
statistical reporting and admin functions
30. ICD-9 and ICD-10: International Classification of Disease-standard
developed by World Health Organization (WHO) contains diagnosis codes
that are used in all health care settings.
31. ICD-9-CM: DIAGNOSIS USAGE: Inpatient & Outpatient
*Number of characters: 3-5 alphanumeric
*Number of Codes: 13,000
PROCEDURE USAGE: Inpatient*
*# of characters: 3-4 numeric
*# of codes 4,000
32. ICD-10-CM: DIAGNOSIS USAGE: inpatient & outpatient
*# of characters: 3-7 alphanumeric
