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Lesson 4: Electronic Records Flashcards

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11170772624Electronic Health Record (EHR)The _____ _____ _____ (_____) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.0
11170772625Discrete data_____ _____ refers to information that consists of separate and limited values, such as distinct points on a numeric scale, with distinct intervals between any two values. It's also referred to as quantifiable information, which can be determined, indicated or expressed.1
11170772626Health information exchange (HIE)_____ _____ _____ (_____) is the transmission of healthcare-related data among facilities, health information organizations and government agencies according to national standards.2
11170772627CPRThe IOM defined the _____ as "an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data," with other uses, as well.3
11170772628In 2003, the IOM report established eight core functions that a computer-based patient record should be capable of performing.1. Health Information and Data. 2. Result Management. 3. Order Management. 4. Decision Support. 5. Electronic Communications and Connectivity. 6. Patient Support. 7. Administrative Processes. 8. Reporting and Population Health Management.4
11170772629c. narrative informationSuzy reported to her doctor that the "extreme heat made her feel agitated, so she shaved her head." This is an example of _____. a. laboratory data b. discrete data c. narrative information d. standards5
11170772630c. data could not be easily shared among providersEarly computerized health records systems tended to be specific to institutions. Because of this, _____. a. some institutions provided inferior care b. doctors did not like certain hospitals c. data could not be easily shared among providers d. providers did not need to share data6
11170772631d. the patientThe Institute of Medicine report, The Computer-based Patient Record: An Essential Technology for Health Care, focused on _____ as the primary beneficiary of the EHR. a. insurance companies b. physicians c. healthcare organizations d. the patient7
11170772632b. linked together a network of healthcare providers in different facilitiesThe Veterans Administration development of the DHCP was important because it _____. a. was the first time computers were used in health care b. linked together a network of healthcare providers in different facilities c. was the first time SRT was ever used in health care d. got the Veterans Administration involved in health care for the first time8
11170772633b. discrete dataPulse 130, blood pressure 122/80 and temperature 100.6 °F is an example of _____. a. laboratory data b. discrete data c. narrative information d. standards9
11170772634a. numerical and easily structuredDiscrete data are _____. a. numerical and easily structured b. clinical narratives c. the only kind of information necessary in the medical record d. not included in the EHR10
11170772635interoperabilityA key element in the electronic record of the future is_____, which refers to the ability for different electronic record software to communicate among multiple machines11
11170772636Standards_____ for electronic records refer to consistent information provided to and from the electronic record software.12
11170772637qualified EHRA _____ _____ "includes patient demographics and clinical health information, and has the capacity to provide clinical decision support; support physician order entry; capture and query information relevant to health care quality; and exchange electronic health information with and integrate such information from other sources.13
11170772638Certified EHR_____ _____ technology "gives assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality and security to help them meet the meaningful use criteria.14
11170772639Meaningful use_____ _____ generally describes the ability to demonstrate quality improvement through the use of electronic records15
11170772640Controlled vocabulary_____ _____ means that a specific set of terms in the electronic record's data dictionary must be used.16
11170772641Health Level Seven (HL7)_____ _____ _____ (_____) develops specifications for electronic healthcare information.17
11170772642personal health record (PHR)One variation of the electronic record is the_____ _____ _____ (_____), which is medical information that the patient maintains.18
11170772643Electronic Data Management System (EDMS)Many healthcare organizations—especially large providers, such as acute-care hospitals and large clinics—have implemented a hybrid medical records system, also known as an_____ _____ _____ _____ (_____).19
11170772644HTML (Hypertext Markup Language)Many know that _____ (_____ _____ _____) was designed to display data and is the most widely used language for web-based documents.20
11170772645XML (Extensible Markup Language), XML_____ (_____ _____ _____) was designed to overcome this limitation, which improves the functionality of the web by letting you identify your information in a more accurate, flexible and adaptable way. _____ is the language of electronic records.21
11170772646There are four basic types of computer networks.1. Client/Server Network 2. Peer-to-Peer Network 3. Local Area Network (LAN) 4. Wide Area Network (WAN)22
11170772647ServerA _____ is a data resource that other computers access for information.23
11170772648host computerSome people call a server a _____ _____, and that analogy works well when you think about the functions a server performs.24
11170772649b. structure of dataTo achieve interoperability, standards are necessary in vocabularies, the technology of information exchange and _____. a. methods of treatment b. structure of data c. billing formats d. medical transcription education25
11170772650a. incorporates word-processed documents into the EHRA "hybrid" medical records system that many hospitals implement is one that _____. a. incorporates word-processed documents into the electronic record b. uses the electronic record only for laboratory results c. does not allow viewing of word-processed documents d. is not part of the EDMS26
11170772651d. Both b and c are trueWhich is true of EDMS? a. They consist of word-processing documents only. b. They use EHRs in conjunction with word-processing documents. c. Clinical narratives are available electronically. d. Both b and c are true27
11170772652b. HTMLWhich is the most widely used language for web-based documents? a. XML b. HTML c. LOINC d. SNOMED CT28

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