Deck 5: Electronic Health Records

Question 1

HL7 is a standards development organization that develops electronic health record (EHR) standards.

Answer 1

True

Question 2

Typically, a patient's medical record number is used as the unique identification number when documents are scanned into automated systems.

Answer 2

True

Question 3

Which of the following is an advantage of a manual record system?

A) Retrieval of information is easily customized.
B) It is easy to abstract information.
C) It improves access to patient information.
D) Training of staff is simple.

Answer 3

Training of staff is simple.

Question 4

One of the first terms used in the period 1970-1980 to describe early medical record automation attempts was the term electronic medical record.

Question 5

Selection and development of manual systems is time consuming.

Question 6

Per Joint Commission standards, all inpatient hospital records must be completed within ____ days after discharge, regardless of the storage media of the record.

A) 5
B) 10
C) 15
D) 30

Question 7

Systems that collect and monitor patient physiological data and record the information are known as _____.

A) patient monitoring systems
B) patient health record systems
C) automated systems
D) electronic monitoring systems

Question 8

A longitudinal patient record is used to describe an electronic medical record maintained and updated by an individual for his or her personal use.

Question 9

A scanner is used to capture a patient's vital signs information.

Question 10

Health information professionals will play a major role in the transformation from a paper patient record environment to a virtual electronic environment.

Question 11

Which of the following is true?

A) Automated record systems can help to prevent drug interactions.
B) Automated record systems have lower start-up costs than do manual systems.
C) Secure electronic communications among patients and providers does not need to be present for communication to occur.
D) In a manual patient record system, many users can access patient information at the same time.

Question 12

Data are defined as

A) a collection of related fields.
B) raw facts.
C) processed information.
D) a collection of related records.

Question 13

Early medical record automation efforts focused on the

A) scanning of documents into imaging systems.
B) development of RHIOs.
C) development of alerts, medication administration records, and provider orders communication and notes.
D) networking between the systems of separate facilities.

Question 14

Electronic medical record systems originated in the late 1980s and were based on imaging and the merging of data from various stand-alone systems.

Question 15

Nurse Robin is using a report that records the late dosing of patients' medications. This report was generated from which type of application?

A) Pharmacy
B) Medical documentation
C) Nursing
D) Administrative

Question 16

A computer-based patient record can link patient information at different locations according to a unique patient identifier.

Question 17

In relation to a hybrid record system, which of the following is false?

A) It helps organizations make the transition to a fully electronic system.
B) It totally eliminates paper record storage.
C) Technical staff is needed.
D) It improves readability in some sections of the record.

Question 18

Suzy Supervisor is working to transition the health information management (HIM) department from a paper system to an electronic system. Currently, each patient's record has a paper history and physical, operative report, and discharge summary, while the progress notes and medication administration records are maintained in an electronic system. This is known as a(n)

A) personal heath record.
B) hybrid record.
C) electronic record.
D) automated record.

Question 19

The ultimate goal of a regional health information organization (RHIO) is to

A) reduce the cost of health care.
B) allow health care providers the opportunity to access patient information that was generated at other locations.
C) reduce the amount of time clinicians spend recording patient information.
D) improve testing results.

Question 20

Low start-up cost is typically an advantage of electronic patient record systems.

Question 21

In a(n) ____________________ system, views of patient records can be customized by users.

Question 22

Sally Smith, a pediatric nurse, is collecting the birth weights of children that have a length of stay in the neonatal intensive care unit longer than 60 days. This represents

A) health information.
B) patient information.
C) health data.
D) clinical data and information.

Question 23

A ________________ patient record contains records from different episodes of care, providers, and facilities that are linked to form a view, over time, of a patient's health care encounters.

Question 24

The term ____________________ was used in the late 1990s to describe systems that were based on imaging and merging data from stand-alone systems.

Question 25

Which of the following is an advantage of an automated system?

A) Low start-up costs
B) Requires untrained staff
C) User resistance is unlikely
D) Eliminates paper record storage

Question 26

Typically, HIM professionals are responsible for ensuring that entries are authenticated and ____________________ in electronic record systems.

Question 27

A RADT system is defined as a

A) registration access discharge transfer system.
B) report access discharge transfer system.
C) retrieval admission discharge transfer system.
D) registration admission discharge transfer system.

Question 28

A(n) _____ includes the merging of data from different data systems into one centralized database.

A) clinical information system
B) automated patient record system
C) clinical data repository
D) hybrid data repository

Question 29

Which of the following will occur in an HIM department that has an electronic record system?

A) Filing of patients' progress notes
B) Pulling records for physician access
C) Notes that are not authenticated
D) Misfiled patient information

Question 30

Which of the following is a disadvantage of a manual record system?

A) increased start-up costs
B) difficult to abstract information
C) staff training is expensive
D) user resistance typically occurs

Question 31

Many facilities have ____________________ quality reviews of scanned documents.

Question 32

The content of a legal medical record must be defined in facility ____________________ and standards for maintaining the security and integrity of the information.

Question 33

Optical disk imaging is also known as ____________________.

Question 34

Nurse Flower is reviewing an electronic report of patient Katie's CBC and urinalysis. This report has most likely been generated as part of a _____ application.

A) patient monitoring
B) pharmacy
C) laboratory
D) radiology

Question 35

Which of the following is a disadvantage of automated systems?

A) Updates of information are not easy.
B) Retrieval of customized information is difficult.
C) Technical staff is needed to maintain the system.
D) There is no downtime.

Question 36

Optical disk imaging uses _____ technology to create an image.

A) microfilm
B) electronic
C) laser
D) ultrasound

Question 37

Which of the following is true in relation to RHIOs?

A) They improve patient care.
B) They eliminate the need to repeat all laboratory testing.
C) All medication errors are eliminated.
D) Patient safety is decreased.

Question 38

The term ____________________ is used currently by the Institute of Medicine (IOM) and HL7 to describe the development of standards that relate to the exchange of clinical health information.

Question 39

The term ____________________ was used in the period 1970-1980 to describe the early medical record automation attempt.

Question 40

A ____________________ is an electronic network of patient medical information gathered from multiple health care organizations in a geographical region.

Question 41

List three nursing application functions.

Question 42

Prior to scanning the paper record, the record is prepped. List the steps that occur in the preparation.

Question 43

Sally Smith, RHIT, is designing a screen to collect information on a patient's medical history. List three fields that should be part of the screen.

Question 44

A ____________________ is a collection of related fields.

Question 45

The CEO of Sunny Valley Hospital has made the following statement: "I want to decide on an electronic record system and implement the system in the next four months." Assume that you are the HIM director and have to respond to the CEOs statement. Defend your response.

Question 46

List three fields that could be recorded on an electronic medical record screen with the heading "Patient Physical Exam."

Question 47

Discuss how the role of HIM professionals will change with the implementation of electronic record systems.

Question 48

Data becomes ____________________ after it is given meaning.

Question 49

Numbers, letters, images, and symbols that are not interpreted or processed are classified as ____________________.

Question 50

A ____________________ is a collection of related records.

Question 51

List two functions that are included in a pharmacy application. Briefly discuss the advantage of a pharmacy application.

Question 52

Discuss the advantages of an individual maintaining a personal health record.

Question 53

In 1991, the IOM produced a report, "The Computer-Based Patient Record: An Essential Technology for Health Care," which outlined processes that electronic records should support. List three items that electronic records should support according to the study.

Question 54

Explain how a record transitional template can be used when a facility transitions to an electronic record system.

Question 55

A group of characters forms a ____________________.