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HCA PT. 1 Exam Questions and Answers 100%
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health record - ANSWER ✔✔-A health record can be defined as written or graphic information
documenting facts and events during the rendering of patient care. Either paper or electronic format.
American Recovery and Reinvestment Act of 2009 (ARRA) - ANSWER ✔✔-encourages implementation
by offering five annual financial incentives for qualifying offices that convert to an electronic format
beginning in 2011 and ending in 2015 or 2016.
Health record content (common) - ANSWER ✔✔-1. Patient registration (demographic information)
2. Medication record
3. history and physical exam, notes or report
4. Progress or chart notes
5. Consultation reports
6. imaging and x-ray reports
7. Laboratory reports
8. Immunization record
9. Consent and authorization forms
10. Operative report
11. Pathology report.
In hospital setting would also include
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- attending physician's orders
- date of admission
- hospital stay dates
- discharge date
- discharge summary
What types of systems are used in electronic health record system (EHR) - ANSWER ✔✔-1. problem-
oriented record (POR system)
2. source-oriented record (SOR system or integrated system)
Problem-Oriented Record System (POR) - ANSWER ✔✔-consists of: flow sheets, charts, or graphs, that
allow aphysician to quickly locate information and compare eaulation
Source-Oriented Record system (SOR) - ANSWER ✔✔-documents are arranged according to sections
(e.g., H&P section, progress notes, lab tests, radiology reports, or surgical operations) SOR system filed in
reverse chronological order. More difficult to locate data due to scattering throughout
Electronic Health Record System - ANSWER ✔✔-collection of medical information about the past,
present and future of a patient that resides in a centralized electronic system.
Difference between an EHR and an EMR - ANSWER ✔✔-An EMR is individual physician's EMR for the
patient, including medical history, allergies, and appointment information.
An EHR is all patient medical information from many information systems, including all components of
the EMR.
Advantages of EHR - ANSWER ✔✔-Advantages of EHR1. no physical space required
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2. abstracting data is eliminated except when free-form documentation such as narrative notes, dictations,
and natural language processing is used.
3. free-text approach, encourages use of abbreviations or fewer spelled out words may result in scant or
undecipherable documents.
4. Electronic systems have built in security safeguards to protect against improper disclosure,
unauthorized access, or unintended alteration of information for both the data and the system.
5. ARRA requires covered entities to notify individuals if their protected health information is accessed or
disclosed in an unauthorized manner.
SNOMED-CT - ANSWER ✔✔-Systemized Nomenclature of Medicine for Clinical Terminology. Medical
terminology cassification system that codes text data in an EHR system will assist in standardizing
clinical medical terminology
Medicare Modernization Act - ANSWER ✔✔-created the Commission on Systemic Interoperability to
develop a strategy to make health care information abailable at all times to patients and physicians. Goal
by 2014.
Electronic medical report - ANSWER ✔✔-part of health record that is used to complete the insurance
claim form.
permanent legal document that formally states outcomes of the patients' examination or treatment in
letter or report form.
Insurance claim - ANSWER ✔✔-- DOS, date of service
- POS, place of service
- Dx, diagnosis
- Procedures
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- codes are used for interpretation by the insurance company when processing a claim
documenters - ANSWER ✔✔-all individuals providing health care services that chronlogically record
pertinent facts and observations about patient's health.
documentation - ANSWER ✔✔-charting, may be electronically handwritten, dictated and transcribed or
downloaded from a (PDA) personal digital assistant or smartphone
speech recognition system - ANSWER ✔✔-computerized voice recognition system which makes it
possible for computer to respond to spoken words
medical editor - ANSWER ✔✔-correctionist, proofreads and edits the computer-generated documents
attending physician - ANSWER ✔✔-refers to the hospital staff member who is legally responsible for the
care and treatment given to a patient
consulting physician - ANSWER ✔✔-provider whose opinion or advice regarding evaluatio or
management of a specific problem is requested by another physician
non-physician practitioner (NPP) - ANSWER ✔✔-nurse practitioner, clinical nurse specialist, licensed
social worker, nurse midwife, physical therapist, speech therapist, audiologist, or physician assistnat who
furnishes a consultation or treats a patient for a specific medical problem, pursuant to state law, and who
use the results of a diagnostic test in the management of the patient's specific medical problem
ordering physician - ANSWER ✔✔-individiual in the hospital directing the selection, preparation, or
administration of tests, medication, or treatment
primary care physician (PCP) - ANSWER ✔✔-oversees the care of the patients in a managed health care
plan and refers patients to see specialists for services as needed
referring physician - ANSWER ✔✔-provider who sends the patient for tests or treatment
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