NHA CEHRS EXAM NEWEST ACTUAL EXAM COMPLETE
200 QUESTIONS AND CORRECT DETAILED ANSWERS
Electronic Health Records - ANSWER: EHRs
Electronic Medical Records - ANSWER: EMRs
EHR technology - ANSWER: large integrated EHR systems and smaller, single-use
EMR software.
Protected Health Information (PHI) - ANSWER: 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) - ANSWER: Privacy and
guidelines for business associates.
Health Information Technology for Economic and Clinical Health - ANSWER: (HITECH)
Act
American Recovery and Reinvestment Act of 2009 (ARRA) - ANSWER: introduced
increased responsibilities and greater punishments for improper management of PHI
Covered entities - ANSWER: 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 - ANSWER: 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. - ANSWER: 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) - ANSWER: The provider inputs an
admission order into the EHR system using this
, Patient Care Orders (PCO's) - ANSWER: 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) - ANSWER:
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) - ANSWER: Report within 24 hours of the patients
admission.
What is a medical record - ANSWER: 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 - ANSWER: Safety
Quality of Care
Efficiency
Cost Reduction
What are clinical standards - ANSWER: 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 - ANSWER: 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.
200 QUESTIONS AND CORRECT DETAILED ANSWERS
Electronic Health Records - ANSWER: EHRs
Electronic Medical Records - ANSWER: EMRs
EHR technology - ANSWER: large integrated EHR systems and smaller, single-use
EMR software.
Protected Health Information (PHI) - ANSWER: 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) - ANSWER: Privacy and
guidelines for business associates.
Health Information Technology for Economic and Clinical Health - ANSWER: (HITECH)
Act
American Recovery and Reinvestment Act of 2009 (ARRA) - ANSWER: introduced
increased responsibilities and greater punishments for improper management of PHI
Covered entities - ANSWER: 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 - ANSWER: 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. - ANSWER: 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) - ANSWER: The provider inputs an
admission order into the EHR system using this
, Patient Care Orders (PCO's) - ANSWER: 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) - ANSWER:
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) - ANSWER: Report within 24 hours of the patients
admission.
What is a medical record - ANSWER: 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 - ANSWER: Safety
Quality of Care
Efficiency
Cost Reduction
What are clinical standards - ANSWER: 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 - ANSWER: 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.
