A physician group is adopting a new electronic health record (EHR). Some members of the group prefer to dictate, and others prefer direct data
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Which data capture method should the EHR coordinator recommend to meet the needs of all physicians?
Template-based entry
A hospital's health information management (HIM) department receives numerous pages of loose documentation on a daily basis to integrate into the patient's electronic chart.
Which procedure should the department consider implementing to improve the electronic record process and ensure documentation is readily available?
Barcoding
An administrator needs to generate reports that show patient utilization trends for the emergency department (ED) on a quarterly basis.
Which system should be used?
R-ADT
Which benefit is provided by a hospital's birth certificate system?
Submission of social security number requests
A hospital has a pharmacy information system (PIS) that is integrated with a computerized provider order entry (CPOE) system. The physician orders medications for an inpatient through the CPOE.
How is healthcare decision-making affected due to the integration of the PIS?
The integration allows the physician to be alerted to contraindication for any medication based on the patient's allergy information.
An emergency department (ED) patient is sent to radiology for a two-view X-ray of the left knee. The X-ray technician uses the hospital's radiology information system (RIS) throughout the exam.
How does the RIS assist the technician?
It helps the technician decide the correct positioning of the patient and ensures image quality.
A primary care clinic encourages its physicians to engage in patient-centered care by actively partnering with patients during healthcare decision-making.
Which technology in the clinic's health information system (HIS) supports this process?
Patient portal
Which medication-related area has benefited from the use of an electronic health record (EHR)?
Improved patient verification with prescribed medication
How does a health information exchange (HIE) improve patient safety?
Allows all physicians caring for a patient to access the same data
A health information management (HIM) system becomes unavailable due to a faulty component in a server. The information technology (IT) staff orders a replacement part to arrive the following morning.
Which need is associated with managing the health information during this downtime?
Access back-up servers to capture historical data
A physician practice office would like to implement a downtime policy.
Which form is used to capture billing for the services provided?
Charge slip
A hospital is in the final phase of implementing an electronic medical record (EMR) system and is concerned about it going down during the go-live phase.
What should the staff do to ensure that data is not lost during any downtime?
Save information on a stand-alone computer that is not part of the project
A nurse on the night shift is preparing to discharge a patient. The patient would like to know the facility charge of the chest X-ray received during the exam. The night shift nurse was unable to access the chargemaster under her log-in credentials.
Which type of access does the night shift nurse need?
Role-based authentication
A master patient index (MPI) analyst has been assigned to combine duplicate health record numbers. A health information management (HIM) technician has been assigned to help but cannot access the hospital information system (HIS).
Which type of authentication does the technician need in order to help?
User-based
Hackers breached a medical center's clinical management database and accessed the data of 1.5 million patients. This breach forced a shut down of the network to contain the virus.
Which strategy would mitigate a future breach and prevent downtime of the electronic health record (EHR)?
Risk analysis
Malware was introduced to a hospital information system when an end-user clicked on a link containing a virus. The virus invaded all computers in the department and brought most of the work to a standstill.
Which strategy plan would re-establish functionality and access while the virus is being extracted?
Contingency plan
Which feature of a quality indicator system is critical to health information management (HIM) department functions, in addition to abstracting clinical information?
Reporting
What is used to automate the dispensing of a patient's medication, ensuring the right medication is given to the right patient?
Bar coded medication administration
What has improved because of electronic document management systems?
Workflow management
Some healthcare facilities use voice and speech recognition software to translate a physician's spoken word to the written word in an electronic document.
What is a benefit of using voice-to-text transcription?
Increased productivity
A health information management (HIM) manager needs to identify incomplete records.
Which type of system should the HIM manager use?
Deficiency tracking
An organization has a large volume of paper records that need to be scanned into the electronic health record (EHR). The health information management (HIM) supervisor needs to establish a plan for backscanning the paper records. Which process should be considered in the plan?
Record availability for continued patient care
Before placing data elements into a new database, the database administrator (DBA) breaks the fields into data elements. These data elements indicate the level of detail for the facility. For example, last name and first name are placed in separate fields to allow the user to easily search the data elements. Which action describes the process of breaking the data elements into level of detail?
Performing normalization
A registration clerk is searching in the relational database for information on a patient.
Which component of the database contains this information?
Record
A data manager needs to generate a report showing the clinical outcomes of patients that have been admitted to the hospital with specific types of injuries. Which system will the data manager use to generate the clinical outcomes report?
Trauma registry system
A flu vaccination manufacturer issued an urgent recall of LOT VF12345 that a clinic was using for the past month. Which unique identifier helps identify patients who were vaccinated?
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