Electronic Health Records
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Course Introduction
This course provides an in-depth exploration of electronic health records (EHRs) and their crucial role in modern healthcare. Students will learn about the design, implementation, and management of EHR systems, as well as their impact on patient care, workflow efficiency, and legal compliance. The course covers topics such as data standards, privacy and security practices, interoperability, user interfaces, and the challenges associated with the transition from paper to digital record-keeping. Practical case studies and hands-on activities will equip students with the skills needed to evaluate, select, and utilize EHR technologies effectively in a healthcare environment.
Recommended Textbook Health Information Technology 3rd Edition by Nadinia A. Davis
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2
Chapter 1: Health Care Delivery Systems
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Q1) Which health care professional is responsible for educating patients about medication regimens from the patient care plan?
A) Health Information Technologist
B) Physician
C) Psychologist
D) Nurse Answer: D
Q2) How are physicians categorized?
A) Geographic location
B) Hospital
C) Medical specialty
D) Age
Answer: C
Q3) The number of beds that the facility actually has set up, equipped, and staffed is the:
A) Licensed beds
B) Bed count
C) Registered beds
D) Certified count
Answer: B
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Page 3
Chapter 2: Collecting Health Care Data
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Q1) Which of the following data sets is used by acute care facilities?
A) MDS
B) OASIS
C) ICD-10-CM
D) UHDDS
Answer: D
Q2) Your facility is using a paper-based record. The HIM department has decided to switch from an integrated record to a completely source-oriented record, postdischarge. You are responsible for training the staff members who assemble the records into the correct order. Which of the following must exist in order to implement this change?
A) All documentation must be changed to reflect the new order.
B) Except for physician's orders, physicians and nurses cannot document on the same page.
C) Nothing has to change; the way the clinicians document information is irrelevant to the chart order.
D) Physicians and nurses must document on the same page.
Answer: B
Q3) A collection or series of related characters is a ________.
Answer: field
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Chapter 3: Electronic Health Records
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Q1) The interface which grants patients web-based access to their medical record is known as a patient ___________.
Answer: portal
Q2) Interoperability means :
A) The ability of software and hardware on different machines from different vendors to share data
B) Incentives for electronic health record (EHR) adoption
C) Computers are not able to communicate with each other
D) Physicians can operate from within a surgical unit
Answer: A
Q3) The HIMSS definition of an electronic health record includes:
A) Provides decision-making capabilities
B) Collection of data
C) Real-time, point of care
D) All of the above
Answer: D
Q4) Active knowledge-making systems which use two or more items of patient data to generate patient specific advice are called clinical ________________ systems.
Answer: decision-making
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Chapter 4: Acute Care Records
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Q1) The extent and complexity of a history and physical are dictated by:
A) TJC guidelines
B) DHHS guidelines
C) Data needed to evaluate the patient's problem
D) All of the above
Q2) What is the documentation standard for History and Physicals (H&Ps) established by the Joint Commission?
Q3) Describe the events that will occur when a patient is admitted to an acute care facility for a surgical procedure. What caregivers will be involved with the patient?
Q4) Which of the following should be collected during the patient registration process?
A) A plan of care, the measures to treat the patient's condition or disease
B) An advance directive, to specify the patient's wishes for his/her care
C) A discharge summary, to recap the patient's stay
D) A history, to document the patient's previous treatments
Q5) When a patient is first seen by a physician in any health care setting, the physician generally records the patient's chief complaint, pertinent family and social data, and a review of the patient's body systems. This record is called the ________.
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Page 6
Chapter 5: Health Information Management Processing
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Q1) Name the steps in ensuring completeness of the medical record and the purpose of each step.
Q2) TJC requires that acute care records be completed:
A) Within 15 days of discharge
B) In whatever time period the facility requires
C) Within 30 days of discharge
D) In whatever time period the state requires
Q3) In a paper environment, records must physically move from the patient care area to the HIM department for processing and storage. Give two examples of how that movement can occur.
Q4) A patient's record was not completed as of the 26th day after the patient's discharge from the hospital. This record is considered:
A) Deficient
B) Delinquent
C) In process
D) Invalid
Q5) List and define the three fundamental types of internal control. Give a postdischarge processing example of each.
Q6) Another word for an incomplete system is a ______________.
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Chapter 6: Code Sets
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Q1) SNOMED-CT is designed for use in and support of the EHR. SNOMED-CT's design does NOT include:
A) Codes embedded in the EHR
B) All of the detail needed to derive ICD-10-CM codes
C) Codes assigned during the course of patient care
D) All of the above are included.
Q2) An example of an ICD-10-CM category code is:
A) C1715
B) 0DJD8ZZ
C) I20
D) 43251
Q3) Can a health care facility choose to use only SNOMED instead of ICD-10-CM? Why or why not? How can these two data sets complement each other?
Q4) When are ICD-10-CM coding changes issued?
A) January of each year
B) April of each year
C) October of each year
D) April and October of each year
Q5) CPT-4 is copywritten by what organization?
Q6) Describe the difference between nomenclature and classification.
Page 8
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Chapter 7: Reimbursement
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Q1) The Medicare patient presented to the emergency department with exacerbation of COPD. The patient was treated and released. The emergency department charges were $430. Two days later, the patient returned to the emergency department with congestive heart failure. The length of stay for the admission was 2 days. The inpatient charges were $4,700. The DRG amount was $3,500. The hospital should bill Medicare for:
A) $3,500
B) $3,730
C) $4,700
D) $5,130
Q2) One major difference between a PPO and an HMO is:
A) Under PPOs, patients can choose any health care provider without penalty
B) HMOs require co-pays
C) HMOs do not typically reimburse for out-of-network providers
D) PPOs require co-pays
Q3) A contractor who manages health care claims for Medicare is a:
A) Blue Cross/Blue Shield organization
B) Fiscal intermediary
C) Medicare PPO
D) Wrap-around policy
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Page 9
Chapter 8: Health Information Management Issues in Other Care Settings
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Q1) All facilities seeking Medicare reimbursement are regulated by __________.
Q2) Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986. How has this law changed the way hospitals handle indigent patients?
Q3) Ambulatory care services are for which type of patients?
A) Primary care physician office visit
B) Overnight observation at hospital
C) Hospice care visit
D) Behavioral health care visit
Q4) A facility-based ambulatory care department that provides general or specialized services such as those provided in a physician's office is called a _______.
Q5) The extracorporeal elimination of waste products from blood is most likely to be performed at a:
A) Dialysis center
B) Laboratory
C) Radiology center
D) Rehabilitation center
Q6) Describe the unique data collection issues in behavioral health care.
Q8) The accrediting agency for rehabilitation is the ___________. Page 10
Q7) Describe the unique data collection issues in home health care.
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Chapter 9: Managing Health Records
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Q1) Shelley is the new health information management file room supervisor at Diamonte Hospital. Upon entering the file room she notices that the files are cramped and there is no room on the shelves to file any new charts. Shelley determines that it is critically necessary to order additional shelving to increase the file shelf space to store all of Diamonte's records. The facility has approximately 3,000 discharges each year. They keep 2 years of paper records on site. The average thickness of a record is 1 inch. They currently have 10 shelving units and each unit has five shelves and is 36 inches wide. How many additional filing units should Shelley order?
A) 24
B) 23
C) 34
D) 33
Q2) Patient health records, whether in paper or electronic form, should be retained for all of the following purposes EXCEPT:
A) Physician's licensing
B) Facility accreditation
C) Insurance reimbursement
D) Continuation of patient care
Q3) What can be done when health records are lost or destroyed inadvertently?
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Page 12
Chapter 10: Statistics
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Q1) A database of specific cancer or trauma information is an example of a ____________.
Q2) Compute the length of stay for the following patient: Admitted 5/25/2012
Discharged 5/25/2012
A) 0 days
B) 1 day
C) Cannot be determined
D) None of the above
Q3) Named and identifiable pieces of data that can be queried and reported in a meaningful way are called ________________.
Q4) Describe circumstances in which a department in the health care organization may request health information or statistics.
Q5) Explain the mean, median, and mode.
Q6) The length of stay for Patient D is _______________.
Q7) Explain the difference between aggregate and patient-specific data.
Q8) A measure of variance called the ______________ shows how closely the observations are distributed around the mean.
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Q9) A report of a group of patients including their age is an example of ____________ data.
Chapter 11: Quality and Uses of Health Information
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Q1) Compare and contrast Juran's and Crosby's quality management theories. How can health care facilities apply these theories?
Q2) A supervisor and her team of employees are confronted with two solutions to a problem. Each solution involves time, money, and space. The supervisor might use a quality management tool called a ___________.
Q3) The predecessor of The Joint Commission was:
A) Hospital standardization
B) AHIMA
C) NCQA
D) ACS
Q4) Ensuring appropriate, efficient, and effective patient care is a process of ___________.
Q5) The ______________ process would be initiated following a patient's fall from the bed, to gather information and coordinate the claim.
Q6) The number of existing cancer cases reported by the tumor registry is known as
Q7) Compare and contrast the Lean and Six Sigma performance improvement methods. How can health care facilities apply these theories?
Page 14
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Chapter 12: Confidentiality and Compliance
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Q1) How is a PHR different from a medical record? How can the PHR assist in maintaining continuity of patient care?
Q2) In some circumstances, patient-specific information can be released without the consent of the patient. List three reasons that information can be released without patient consent.
Q3) What is jurisdiction? List examples of issues over which municipal, state, and federal courts may have jurisdiction.
Q4) In litigation, lawyers may request documentation from the HIM department during the ___________ process.
A) certification
B) filing
C) pretrial hearing
D) discovery
Q5) An officer of the court's direction to produce documents is called:
A) Subpoena duces tecum
B) Subpoena ad testificandum
C) malfeasance
D) jurisdiction
Q6) What HIPAA provisions did the HITECH extend? Name and discuss at least two.
Page 15
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Chapter 13: Him Department Management
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Q1) An HIM department budgets 3 full-time equivalents (FTEs) for coding. If a full-time employee usually works 40 hours a week, how many hours per week are available for coding?
A) 3 hours
B) 40 hours
C) 120 hours
D) 100 hours
Q2) Diamonte Hospital's fiscal year runs from October 1 through September 30. Which of the following months are in the third quarter?
A) January, February, March
B) April, May, June
C) July, August, September
D) October, November, December
Q3) Broken lines on an organization chart indicate:
A) Line responsibility
B) Authority
C) Indirect or shared responsibility
D) Departments or positions
Q4) Under what circumstances will a health care facility outsource an HIM function?
Q5) Explain how delegating can improve a manager's effectiveness.
Page 16
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Chapter 14: Training and Development
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Q1) Because part of health care delivery is customer service, health care employees are encouraged to develop a positive customer focus by doing all of the following EXCEPT:
A) Identify customers by name.
B) Greet each customer with a smile
C) Provide assistance if there is a need.
D) Do not return patient phone calls if the employee does not have the answer to their question.
Q2) HIM department employees are in constant need of continuing education. Identify specific continuing education needs for the following HIM employees: credentialed employees, coding employees, release of information.
Q3) What subjects has AHIMA deemed core content for the HIM profession? Name at least five and detail how to obtain continuing education for these core content subjects.
Q4) Organize an agenda for HIM department meetings. Using the agenda set up a format for the minutes that must be taken during this meeting. Include a list of all materials that must be kept to document the meeting.
Q5) Explain three aspects of leadership and provide an example of how they can be accomplished.
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