DPRC CERTIFICATION TEST

Question 1

A health record on a computer is known by a variety of terms, name them

Answer 1

Electronic health record (EHR), Electronic medical record (EMR), or Computer-based record

Question 2

What’s the umbrella term developed by DPRC

Answer 2

Digital patient record

Question 3

The __________ __________ _________ is an important and growing _________ of the modern ____________ system

Answer 3

Digital patient record, facet, healthcare

Question 4

Healthcare facilities that use ______ ________ _______ are more likely to be __________ and less _______ to ________ errors.

Answer 4

digital patient record, efficient, prone, costly

Question 5

Workers _______-_______ in digit patient records will ________ be ______ out by _________

Answer 5

well-versed, increasingly, sought, employers

Question 6

PHR

Answer 6

Protected health record

Question 7

DPRC will help you master the skills you need to work in an environment where _______ _______ information — all individually __________ ______ _______ created, _______, ______, or ______ by a healthcare _______ – can be called up on a _______ _______.

Answer 7

protected health, identifiable health information, transmitted, received, maintained, entity, computer screen

Question 8

_______ _______ is an emerging industry, with _______ having ______ ______ in other countries.

Answer 8

Medical tourism, patients, major surgery

Question 9

With ______ _____ ______, a_______ information can be _______ and moved more easily than with a _______ _______.

Answer 9

digital patient record, patient;s shared, paper record

Question 10

In what year was a vision from the digital patient record created?

Answer 10

early 1990

Question 11

What was the name of the landmark report of the Institute of Medicine titled and when was it released?

Answer 11

The Computer-Based Patient Record: An Essential Technology for Health care released in 1991

Question 12

The vision of the landmark report by the IOM laid out a broad vision of what?

Answer 12

computer-based patient record that would follow a person from cradle to grave and serve the healthcare provider that cared for that patient with rich functionality.

Question 13

How was the landmark report by the IOM effective?

Answer 13

The report was effective in establishing electronic health records as an “establishment” policy objective.

Question 14

In the 1990’s EHR had generated sufficient evidence of their potential to improve the safety and quality of healthcare that two additional reports were written by the IOM name them

Answer 14

To Err Is Human and Crossing the Quality of Chasm

Question 15

The IOM identified six goals for quality in health care systems name them

Answer 15

1. safety
2. equity
3. effectiveness
4. efficiency
5. patient-centerness
6. timeless

Question 16

The IOM identified 5 strengths of paper medical records from the perspective of the record user what are they

Answer 16

1. familiarity: users don’t have to acquire skills to use paper records
2. portability: Paper records can be carried by the clinician to the patient
3. No downtime: Once in hand, paper records do not experience downtime as computer systems do
4. Flexibility in recording: Paper records allow flexibility in recording data and information, including subjective data
5. Browsing: Paper records can be browsed through or visually scanned.

Question 17

Despite the strengths paper records have weaknesses, what are they?

Answer 17

1. Content issues
   - —Missing data, inaccurate data, and illegible handwriting. Illegible handwriting has led to many well-documented injuries and deaths of patients
2. Poor format
   - –Lack of order, logic, and organization
3. Poor access, availability, retrieval
   - –A patient could be seen at a satellite clinic while his paper record is at another location
4. Lack of linkages and integration
   - –Weak or non-existent integration between inpatient and ambulatory paper records
   - –Lack of easy ways to view relevant medical evidence

Question 18

The EHR facilitates a patient-provider encounter from start to finish. True/False

Answer 18

True

Question 19

There are advantages of digital patient records. Before entering the exam room, the clinician can log onto the patient’s EHR, to find, among other things: such as

Answer 19

1. active medical problems
2. current medications
3. past medical history
4. past lab results
5. recent radiology procedures, with full radiology report or thumbnail of the actual images
6. allergies
7. brief, pertinent demographics and social history, such as age, occupation, and marital status
8. dates and reasons for past visits with full doctor’s notes

Question 20

What are some advantages of EHR during the office visit

that the clinician is capable of doing?

Answer 20

1. add to the problem list
2. see options for treatment of the new problem
3. print out patient education materials
4. enter fully specified medication order (drug name, dose, route, and frequency)
5. send the prescription to the pharmacy
6. enter a desired follow-up interval
7. add notes in a structured note template. which includes prompts for completeness and adherence to standards of care

Question 21

Name the key advantages digital patient records have over paper records.

Answer 21

1. Better access
   - –Many physicians now routinely access much or all of the information they need to care for a patient from their office, at a hospital, or in their homes through digital patient record
2. Quality of data
   - –Missing data can be greatly reduced by building in prompts that a clinician needs to respond to before closing the record
   - –Inaccurate data can be minimized by adding simple data-checking mechanisms
3. Quality of care
   - –The EHR can assist clinicians in providing a safe and more effective care by using CPOE.
   - –legibility issues are eliminated using CPOE
   - –Dosing, contraindication, and advice is presented to the provider at the time of medication ordering, resulting in safer medication orders
4. Continuity of care
   - –Regional health information (RHIO) have formed in many states and regions facilitating the exchange of digital patient information from physician offices to hospitals, and from hospitals to complanies
5. Facilitation of medical, health services and public health research
   - –Under proper authorization, the EHR makes higher-quality data readily available at much lower cost to researchers.

Question 22

The use of CPOE, eliminating legibility issues, dosing, contraindication are example of

Answer 22

Quality of care which is one of the advantages of digital patient record

Question 23

A registered vocabulary of HL7 incorporated into the Nation Library of Medicine’s Unified Medical Language System in 1998, describing the procedures, treatments, and services provided during an encounter with a complementary and alternative medicine, nursing, and other integrative medicine, nursing, and other integrative healthcare provider

Answer 23

ABC Codes

Question 24

The use of computer software that automatically generates a set of medical codes for review/validation and/or use based upon clinical documentation provided by healthcare practitioners.

Answer 24

Computer-assisted coding (CAC)

Question 25

The division of the Department of Health and Human Services that is responsible for developing healthcare policy for the United States and for administering the Medicare program and the portion of the Medicaid program; called the health Care Financing Administration prior to 2001

Answer 25

Center for Medicare and Medicaid Services (CMS)

Question 26

A coding system developed by the dental profession; formerly called the Uniform Code pm Dental Procedures and Nomenclature

Answer 26

Current Dental Terminology (CDT)

Question 27

A comprehensive list of descriptive terms and codes published by the American Medical Association and used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians.

Answer 27

Current Procedural Terminology (CPT)

Question 28

A unit of case mix classification adopted by the federal government and some other payers as a prospective payment mechanism for a hospital inpatients in which disease are placed into groups because related disease and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost.

Answer 28

Diagnosis-related Group (DRG)

Question 29

A nomenclature to standardize the diagnostic process for patients with psychiatric disorders; includes codes that correspond to ICD-9CM codes

Answer 29

Diagnostic and Statistical Manual of Mental Disorders (DSM)

Question 30

A standard for the distribution and viewing of any digital image regardless of its source.

Answer 30

Digital Imaging and Communications in Medicine (DICOM)

Question 31

An independent nonprofit health services research agency establish to promote safety, quality, and cost-effectiveness in healthcare to benefit the patient care through research, publishing, education, and consultation; formerly called the Emergency Care Research Institute.

Answer 31

ECRI

Question 32

Federal agency responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, the nation's food supply, cosmetics, and products that emit radiation.

Answer 32

Food and Drug Administration (FDA)

Question 33

A non-profit foundation established in 1999 that, along with its practitioner association constituents coordinates terminology development in ABC codes.

Answer 33

Foundation for Integrative Healthcare (FIHC)

Question 34

The legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs and guarantee the security and privacy of health information.

Answer 34

Heath Information Portability and Accountability Act (HIPPA)

Question 35

A three-level classification system introduced in 1983 to standardize the coding systems used to process Medicare and Medicaid.

Answer 35

Healthcare Common Procedure Coding System (HCPCS)

Question 36

The communications protocol that enables use of hypertext linking.

Answer 36

Hypertext transport protocol (HTTP)

Question 37

A classification system used for reporting incidences of malignant disease

Answer 37

International Classification of Diseases-Oncology (ICD-O)

Question 38

A classification system used in the United States to report morbidity information.

Answer 38

International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM)

Question 39

The most recent revision of the disease classification system developed and used by the World Health Organization to track morbidity and mortality information worldwide.

Answer 39

International Classification of Disease, Tenth Revision (ICD-10)

Question 40

A classification system developed by the World Health Organization in 2001 that describes how people live with their health conditions.

Answer 40

International Classification of Function, Disability, and Health (ICF)

Question 41

A database protocol developed by the Regenstrief Institute for healthcare aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research.

Answer 41

Logical Observation Identifiers, Names, and Codes (LONIC)

Question 42

A proprietary clinical terminology developed as a point-of care tool for electronic medical record documentation at the time and place of patient care.

Answer 42

MEDCIN

Question 43

A vocabulary developed as a pragmatic, clinically validated medical terminology with an emphasis on ease-of-use data entry, retrieval, analysis, and display, with a suitable balance between sensitivity and specificity, within the regulatory environment.

Answer 43

Medical Dictionary for Regulatory Activities (MedDRA)

Question 44

A classification of nursing diagnoses adopted by the North American Nursing Diagnosis Association. This system describes patients' reactions to diseases rather than classifying the condition of diseasesd and disorders.

Answer 44

NANDA

Question 45

A code set used for medical codes maintained and approved by the FDA; the code set designated by the Department of Health and Human Services for reporting drugs and biologics on standard retail pharmacy transactions.

Answer 45

National Drug Code (NDC)

Question 46

A nonproprietary drug reference terminology that includes drug knowledge and classifies drugs, mostly notably by mechanism of action and physiologic effect.

Answer 46

National Drug File-Reference Terminology (NDF-RT)

Question 47

The United States' vision for a national health information infrastructure that makes secure transmission of person-specific health information from one location to another. NHIN is synonymous with the national health information infrastructure.

Answer 47

National Health Information Network (NHIN)

Question 48

A standardized classification of interventions that nurses do on behalf of patients in all care domains.

Answer 48

Nursing Interventions Classification (NIC)

Question 49

A standardized classification of outcomes developed for use in all settings and with all patient populations. It was developed to evaluate the outcomes of nursing interventions.

Answer 49

Nursing Outcomes Classification (NOC)

Question 50

A type of reimbursement system based on preset payment levels rather than actual charges billed after a service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary's condition.

Answer 50

Prospective Payment System (PPS)

Question 51

A nonproprietary terminology developed by the National Library of Medicine that represents drugs at the level of granularity needed to support clinical practice.

Answer 51

RxNorm

Question 52

A comprehensive taxonomy that contains codes for identifying not only diseases and diagnoses, but also anatomy, conditions, morphology, and social factors that may affect health or treatment.

Answer 52

Systematized Nomenclature of Dentistry (SNODENT)

Question 53

A comprehensive clinical terminology, originally created by the College of American Pathologists (CAP) and, as of April 2007, owned, maintained, and distributed by the International Health Terminology Standards Development Organization (IHTSDO), a non-for-profit association inDenmark.

Answer 53

Systematized Nomenclature of Medicine Clinical Terms (SNOWMED CT)

Question 54

A standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement.

Answer 54

Terminology, clinical

Question 55

A multipurpose resource that includes concepts and terms from many different developed source vocabularies.

Answer 55

Unified Medical Device Nomenclature System

Question 56

A standard international nomenclature and computer coding system for medical devices; developed by ECRI.

Answer 56

Universal Medical Device Nonmenclature (UMDNS)

Question 57

The United Nations' specialized agency created to ensure the attainment by all peoples of the highest possible level of health; the international organization responsible for a number of international classifications, including The International Statistical Classification of Diseases & Related Health Problems (ICD-10) and The International Classification of Functioning, Disability & Health (ICF)

Answer 57

World Health Organization (WHO)

Question 58

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization

Answer 58

Electronic Health Record

Question 59

An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

Answer 59

Electronic medical record

Question 60

The electronic movement of health-related information among organization according to nationally recognized standards

Answer 60

Health Information Exchange

Question 61

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

Answer 61

Personal Health Record

Question 62

An organization that oversees and governs the exchange of health-related information among organization according to nationally recognized standards. A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community. The full report from the Alliance includes the specific definitions and summarizes the deliberations and conclusions of the two work groups

Answer 62

Regional Health Information Organization

Question 63

What are the 4 purposes of population records?

Answer 63

1. Administrative and or business operations such as reimbursement for services rendered. 2. Clinical groups for outcome management 3. Public health/bio-surveillance 4. Research

Question 64

A database within an HIS containing unique identification codes for all the patients in a healthcare system

Answer 64

Master patient index (MPI)

Question 65

Sometimes call the hotel function of healthcare information systems. Allows staff to admit pt to a healthcare facility and a specific bed, move pt to or across facilities with an enterprise and discharge pts

Answer 65

Admission, discharge, transfer (ADT)

Question 66

Coding modules that assist medical record and other personnel to properly categorize a diagnosis so organization can get reimbursement

Answer 66

Diagnosis-relates group (DRG) coding

Question 67

Security of medical information is the responsibility of every healthcare worker and healthcare professional. This includes:

Answer 67

Controlling access to a EHR or other systems that contain protected health information Protecting the data from destruction

Question 68

A log of each user and what is viewed and accessed in any amount of time.

Answer 68

Audit trail

Question 69

Has become a critical tool for managing the security of data. Often used in detecting security violations and support for disciplinary actions. Can be a large amount of Dara in any facility.

Answer 69

Audit trail

Question 70

When coming across records your not suppose to see what's your responsibility? What is this called?

Answer 70

To use judgement and ethics. This is called Accidental viewing

Question 71

People set on a criminal intent will attempt access DPR. It's a constant threat in health information

Answer 71

Malicious damage

Question 72

An outsider who attempts to hack or plant software viruses and worms. Often called Trojan horse programs.

Answer 72

Malicious damage

Question 73

Accessing records without proper control. Taping passwords to monitor or walking away from a terminal without logging off threatens the security of a system.

Answer 73

Uncontrolled access

Question 74

A non-profit professional organization of health information managers, historically the medical records professionals

Answer 74

American Health Information Management Association. (AHIMA)

Question 75

AHIMA stands for?

Answer 75

American Health Information Management Association

Question 76

Another word aggregate data is

Answer 76

Population data

Question 77

A non-profit professional organization of biomedical and health informaticians, consisting of health professionals with expertise in the appropriate use of information technology to transform health and healthcare.

Answer 77

American Medical Informatics Association (AMIA)

Question 78

Promotes access to medical care for consumers and health professionals via telecommunications technology.

Answer 78

American Telemedicine Association (ATA)

Question 79

A profession organization of health information management executive, e.g., those IT professionals who run systems in healthcare organizations

Answer 79

College of HeALth InformaTion Management Executives (CHIME)

Question 80

An independent non-profit multi-stakeholder organization whose mission is to grove improvement in the quality, safety, and efficiency of healthcare through information and information technology.

Answer 80

eHealth Initiative (eHI)

Question 81

A healthcare industry membership organization focused on providing leadership for the optimal use of healthcare information technology (IT) and management systems for the betterment of healthcare

Answer 81

Healthcare Information and Management Systems Society

Question 82

The agency of government primarily responsible for the research and education with respect to healthcare quality and research

Answer 82

Agency for Healthcare Research and Quality (AHRQ0

Question 83

A committee chaired by the current secretary of Health and Human Services whose aim is to speed the adoption of health information technology in America

Answer 83

American Health Information Community (AHIC)

Question 84

A government initiative that adopts standards for domains related to health information for federal health data systems, facilitating communication among all federal health agencies.

Answer 84

Consolidated Health Informatics (CHI)

Question 85

The office of the Secretary of Department of Health and Human Services whose responsibility it is to coordinate federal activities with respect to health information technology

Answer 85

Office of the National Coordinator for Health Information Technology (OTC)

Question 86

The federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States.

Answer 86

National Center for Health Statistics (NCHS)

Question 87

A public policy advisory board that recommends policy to the National Center for Health Statistics and other health-related federal programs

Answer 87

National Committee on Vital and Health Statistics (NCVHS)

Question 88

The branch of the National Institutes of Health whose mission is to provide access to current and historical scientific information relating to health and healthcare. The site for MedLine and PubMed

Answer 88

National Library of Medicine (NLM)

Question 89

An agency that coordinates the development of voluntary standard to increase global competitiveness in a variety of industries, including healthcare

Answer 89

American National Standards Institute (ANSI)

Question 90

A scientific and technical organization for the development of standards on characteristics and performance of materials. The character includes products, systems and services, as well as materials, ASTM is the largest non-government source of standards in the Untied States, comprised of more than 130 committees that publish 10,00 standards annually.

Answer 90

American Society for Testing and Materials

Question 91

A set of standards from the voluntary work participants representing all interests concerned (industry, authorities, and civil society) contributing mainly through their national standards bodies

Answer 91

CEN (European Committee for Standardization )

Question 92

Why is the verification step important?

Answer 92

Because it is not uncommon to have two patients with the same last name or even the same first and last names

Question 93

With the EHR, one _______ and _______ a patient record by ________ on to the EHR.

Answer 93

locates, verifies, logging

Question 94

Depending on the setting, the _______ may have to select a ______ ______ or ______ _____ first.

Answer 94

user, clinical group, care area

Question 95

When the user clicks OK on the patient selection screen of the digital patient record she is then see what?

Answer 95

The Cover Sheet

Question 96

If you cannot find a patient what feature would you use to find the patient?

Answer 96

The search feature

Question 97

What would you put in the search feature to find a patient?

Answer 97

A unique identifier

Question 98

If one has all of the relevant record numbers for a given patient, they can be assembled electronically if there is a

Answer 98

master patient index

Question 99

What charts by acquiring the chart?

Answer 99

the navigation

Question 100

navigation through the record by ________ divider sheets that ______ the patient record into _________

Answer 100

tabbed, divide, section

Question 101

Name some examples of sections of a patient record include

Answer 101

History/Physical, Lab, Radiology, Consults, and Progress Notes

Question 102

Assisting some else to access a specific laboratory test, radiology exam or other investigation is called

Answer 102

viewing a result

Question 103

A blood sample taken from a patient and processed by clinical lab is

Answer 103

D-dimer

Question 104

Name some typical divisions of lab and radiology

Answer 104

Clinical laboratory -anatomic pathology, microbiology, cytology, serology Radiology -CT, MRI, PET, molecular

Question 105

Radiology departments are organized by

Answer 105

body system and result functions

Question 106

who defines a legally authenticated document or entry as "a status in which a document or entry has been signed manually or electronically by the individual who is legally responsible for that document or entry

Answer 106

HL7

Question 107

who recommends that an authenticated record has date and time when the individual who is legally responsible input the entry

Answer 107

AHIMA

Question 108

when assessments are done by nursing students entries can only become legally authenticated when a supervising, legally responsible staff member does what?

Answer 108

co-signs

Question 109

Verbal orders are discouraged because

Answer 109

they were found to be the cause of medical errors

Question 110

The important regulatory body in the healthcare industry

Answer 110

JCAHO

Question 111

Who states, Care is considerate and respectful of the patients' personal values and beliefs

Answer 111

JCAHO

Question 112

It is inappropriate for any entry to be disparaging or disrespectful to a patient or his family or friends. Who states this law

Answer 112

JCAHO

Question 113

AHIMA recommends the following procedures in the event of an error for paper record

Answer 113

In a paper record: no use of white out or black out with a marker or write over an mistaken entry draw a line through the entry, make sure that the inaccurate information is still legible write error by the incorrect entry in the margin or above the note sign and date the entry document the correct information

Question 114

AHIMA recommends the following procedures in the event of an error for a EHR

Answer 114

most systems have the ability to track changes or corrections the original entry should be visible enter the current time and date person making changes should be identified and the reason noted the hard copy must also be corrected a symbol that indicates a new or additional entry a preferred method is apply a strikethrough for error with date and time and author stamp or equivalent

Question 115

When might a new EGR be created and a new record number created

Answer 115

birth, a new pt to the organization, or accident or emergency

Question 116

The organizing of clinical information, usually a database. Patient-level information is stored with many other patient information. Can as simple request such as the laboratory results for the patients I saw yesterday, evidence of toxic chemical exposure to combatants of Iraq war

Answer 116

aggregate patient-information

Question 117

Name the four aspects of HIS

Answer 117

Administrative, Departmental, Clinical, Financial

Question 118

Name some administrative modules of HIS

Answer 118

Master patient index, Admission, discharge, transfer, Disgnosis-related group coding,

Question 119

Name some departmental modules of HIS

Answer 119

Laboratory information systems, Radiology information systems, Picture archiving and communications systems, Pharmacy

Question 120

Name some clinical modules of HIS

Answer 120

Provider or physician order entry, clinical documentation , bar-code medication administration (BCMA), decision support

Question 121

Name some financial modules of HIS

Answer 121

Billing, Payroll, Material management