Electronic Health Records Key Concepts

Questions and Answers

Which of the following is necessary for computer systems to exchange information?

Compatibility

Integration

Interconnectivity

Interoperability (correct)

Where can an EHR specialist find documentation to verify the time of a medication administration?

MAR

Before a surgical procedure, an EHR specialist should obtain what to ensure payment of the claim by the third party payer?

Preauthorization

Anyone who thinks a healthcare provider has violated HIPAA privacy regulations can file a written complaint within how many days to the Office for Civil Rights (OCR)?

180 days Signup and view all the answers

What is a threat to the security of information in an EHR system?

Environmental factors Signup and view all the answers

Who analyzes medical codes for patient encounters and reports any errors?

Claim scrubber Signup and view all the answers

In what area of a patient's EHR will the EHR specialist find the necessary documentation to substantiate a short-term disability claim for a woman on maternity leave?

Discharge summary Signup and view all the answers

What is a benefit of documenting a patient encounter at the point of care?

Improved patient outcomes Signup and view all the answers

What is a feature of a patient portal within an EHR system?

Patients can input health status updates between appointments Signup and view all the answers

A patient presents to a provider's office with a third degree burn on his hand from cooking oil. What should an EHR specialist code first?

Classification Signup and view all the answers

For what reasons should an EHR specialist run a statistical report containing information about patients' colonoscopies and fecal occult blood tests?

Performance-based pay Signup and view all the answers

What refers to a provider's liability for the wrongful acts of his employees?

Respondeat Superior Signup and view all the answers

What can be integrated with an EHR system to automatically generate ICD and CPT information directly from clinical documentation?

Computer-assisted coding Signup and view all the answers

What safeguard includes authentication controls for a patient's PHI?

Technical Signup and view all the answers

What is a feature of clinical decision support?

Allows patient care to be tailored to published guidelines Signup and view all the answers

What should an EHR specialist look for as part of a routine chart audit?

Assignment of Benefits form Signup and view all the answers

What is the first step of the scanning process?

Document preparation Signup and view all the answers

A provider's office is using coding software with the ability to receive updates twice a year. What code follows this updating schedule?

ICD-9-CM Signup and view all the answers

If a patient has insurance that requires a co-payment, what is needed to accurately collect and post the patient's payment?

Encounter form Signup and view all the answers

What describes the reference used to enter diagnosis codes in a hospital setting?

ICD-9-CM Signup and view all the answers

An EHR specialist enters a patient's insurance information into the EHR system. How long does it take for this information to post to the patient's chart?

As soon as the information is entered Signup and view all the answers

What is the coding system used to convert written diagnoses into numeric form?

ICD Signup and view all the answers

What is a function of the Drug Utilization Review (DUR) feature in an EHR system?

To flag possible medication interactions Signup and view all the answers

What report indicates the status of a claim since submission?

Aging report Signup and view all the answers

From what part of a SOAP note should an EHR specialist abstract a diagnosis?

Assessment Signup and view all the answers

What computerized documents would an EHR specialist generate to obtain a patient-specific list of procedures, services, and supplies with associated costs?

Charge description master Signup and view all the answers

Storing backup data or media in an off-site location is an example of what?

Physical safeguard Signup and view all the answers

Hospital A was recognized for its employee safety record, and hospital B has set a goal to achieve similar results. This is an example of what?

Benchmarking Signup and view all the answers

Billed procedures and services should be supported by what?

Medical record Signup and view all the answers

What is included in an implant registry?

Manufacturer Signup and view all the answers

An EHR specialist is accessing her facility's provider database. What is she looking for?

Specialty referrals Signup and view all the answers

What is a comprehensive clinical vocabulary designed to encompass all terms used in healthcare?

SNOMED-CT Signup and view all the answers

What represents PHI?

Patient's medical record number Signup and view all the answers

What is an advantage of using clinical templates to record patient encounters?

Standardized documentation formats Signup and view all the answers

Prior to transmitting claims, an EHR specialist is reviewing provider documentation on each claim being billed. What must be documented in the patient chart for each encounter?

Provider's signature Signup and view all the answers

A provider performs a chest x-ray before and after the placement of a chest tube. This repeat procedure should be coded with what?

Modifier Signup and view all the answers

During an office visit, a provider examines a 9-month-old patient for a diaper rash. What type of code should the EHR specialist use to define this type of visit?

Evaluation and Management codes Signup and view all the answers

What is the most important reason to maintain an inventory of software used in an office?

To deter unauthorized duplication Signup and view all the answers

A patient who has Medicare coverage opts to have a procedure performed that is not covered. What form is the patient required to sign?

Advanced Beneficiary Notice Signup and view all the answers

Which part of the financial information system would be used to manage aging reports by guarantor or carrier?

Claims management Signup and view all the answers

An EHR specialist is coding a claim for a patient who fell off a chair and broke an arm. What coding tool is necessary to explain the patient's condition in full?

E codes Signup and view all the answers

An EHR specialist is monitoring changes to CPT codes for his facility. These code changes are managed and updated by who?

AMA Signup and view all the answers

When purging inactive health records, what piece of information must an EHR specialist retain?

Birth date Signup and view all the answers

What demonstrates the use of an aging report?

Healthcare providers must track the amounts of money due from both patients and insurance carriers Signup and view all the answers

What federal act mandates physical, technical, and administrative safeguards?

HIPAA Title II Signup and view all the answers

A clinician is recording patient information. What information should a clinician document as subjective?

Chief complaint Signup and view all the answers

What is an automated benefit of using an EHR system at the time of service?

Providing decision support Signup and view all the answers

A patient is being seen in a clinic for a follow-up visit. The medical assistant has gathered the patient's vital signs. Where should this information be entered?

EMR Signup and view all the answers

What is the most important reason that the provider should include comprehensive documentation in the patient record?

To administrate medical necessity that ensures correct payment to the provider Signup and view all the answers

What should an EHR specialist do after entering diagnosis and procedural codes in an office using an EHR system?

Submit claims for reimbursement Signup and view all the answers

Health Level 7 (HL7) is used to...?

Exchange information between systems Signup and view all the answers

The scheduling template within an EHR system can be used for...?

Identifying a lack of resources that interferes with workflow Signup and view all the answers

What is included on a face sheet?

Advanced directives Signup and view all the answers

What should a provider's office document to demonstrate it is HIPAA compliant?

Audit trail results Signup and view all the answers

An EHR specialist is coding for the reimbursement of durable medical equipment. What code set should she use?

HCPCS Signup and view all the answers

What is the maximum number of days a provider's office has to notify patients when there is a breach to medical record security?

60 days Signup and view all the answers

What does the Office of Inspector General recommend as part of a facility's compliance plan?

Conduct of charts for billing accuracy Signup and view all the answers

An EHR-based provider's office is expanding from two employees to five. What action is the most important to maintain security of protected health information?

Set up role-based access controls Signup and view all the answers

According to HIPAA, the use of CPT and ICD-9-CM code sets is required for...?

Electronic Data Interchange Signup and view all the answers

What patient's right does HIPAA regulations address?

To access personal diagnosis history Signup and view all the answers

Proper documentation to support reimbursement of services is the responsibility of what member of the healthcare team?

Clinician Signup and view all the answers

What allows for entering and retrieving data, and is a special programming language for databases?

SQL Signup and view all the answers

Study Notes

Electronic Health Records (EHR) Key Concepts

Interoperability is essential for computer systems to exchange health information effectively.
MAR (Medication Administration Record) contains documentation verifying the timing of medication administration.
Preauthorization is required before surgical procedures to ensure third-party payer claims are accepted.
Complaints regarding suspected HIPAA violations can be submitted to the Office for Civil Rights (OCR) within 180 days.
Environmental factors pose threats to the security of information within EHR systems.
Claim scrubbers analyze medical codes linked to patient encounters and report errors to improve accuracy.
The discharge summary in a patient’s EHR provides information needed for short-term disability claims related to maternity leave.
Documenting patient encounters at the point of care results in improved patient outcomes.
A patient portal feature allows patients to update their health status between appointments.
When coding a third-degree burn from cooking oil, classification coding should be prioritized.

Quality Measures and Reporting

Running statistical reports on colonoscopies and fecal occult blood tests supports performance-based pay initiatives.
Respondeat Superior outlines a provider's liability for the wrongful acts of employees.
Computer-assisted coding can integrate with EHR systems to generate ICD and CPT codes from clinical documentation.
Technical safeguards encompass controls such as authentication to protect patient Health Information (PHI).
Clinical decision support features help tailor patient care to align with published guidelines.

Documentation and Compliance

Routine chart audits should check for an Assignment of Benefits form.
The first step of scanning documents into an EHR is document preparation.
Coding updates for the ICD-9-CM occur twice a year as part of the coding software.
An encounter form is required to accurately collect patient payments when a co-payment is necessary.
The ICD-9-CM coding system serves as the reference for entering diagnosis codes in hospital settings.

Insurance and Claims Management

Patient insurance information is posted in the EHR as soon as it is entered.
The ICD coding system converts written diagnoses into numeric formats for uniformity.
The Drug Utilization Review (DUR) functionality flags potential medication interactions to promote patient safety.
An aging report monitors the status of claims after submission.
Diagnoses should be abstracted from the Assessment section of a SOAP note (Subjective, Objective, Assessment, Plan).

Best Practices and Security

Charge description master documents include specific details about procedures, services, and prices.
Storing backup data off-site serves as a physical safeguard for data security.
Benchmarking involves comparing safety records or performance metrics against other organizations.
Medical records must support all billed procedures and services for claims to be valid.
An implant registry tracks details such as the manufacturer's information.

Clinical and Administrative Functions

Accessing the provider database in an EHR system helps locate specialty referrals.
SNOMED-CT is a comprehensive clinical vocabulary encompassing all healthcare terms.
The chief complaint is documented as subjective information in patient records.
Adding comprehensive documentation in medical records is crucial for establishing medical necessity and adherence to payment guidelines.
Claims for durable medical equipment should utilize the HCPCS code set.

Regulatory Compliance and Roles

HIPAA Title II mandates the implementation of physical, technical, and administrative safeguards to protect patient information.
Clinicians are responsible for ensuring proper documentation that supports reimbursement of healthcare services.
EHR systems need role-based access controls for enhanced security, particularly in settings experiencing staff increases.
Electronic Data Interchange (EDI) requires the usage of CPT and ICD-9-CM code sets under HIPAA requirements.
Patients have the right to access their personal diagnosis history as outlined by HIPAA regulations.

Technical Aspects of EHR Management

An SQL programming language facilitates data entry and retrieval within database systems.
Compliance plans should include conducting chart reviews to measure billing accuracy as recommended by the Office of Inspector General.
Following a security breach in medical records, the maximum notification period for affected patients is 60 days.

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Description

Test your knowledge about key concepts related to Electronic Health Records (EHR). This quiz covers interoperability, medication administration records, preauthorization processes, and HIPAA compliance among other important topics. Understand how these elements contribute to healthcare and patient outcomes.