Posted: July 28th, 2023

ADMINISTRATIVE AND CLINICAL USE OF THE EHR Questions

ADMINISTRATIVE AND CLINICAL USE OF THE EHR
Administrative and Clinical Use of the EHR

Electronic health records (EHRs) are digital versions of patients’ medical histories, diagnoses, treatments, medications, allergies, and other health information. EHRs can improve the quality, safety, efficiency, and coordination of health care by facilitating communication, decision making, and documentation among health care providers and patients. EHRs can also support administrative and clinical functions such as billing, scheduling, ordering, prescribing, reporting, and research.

Benefits of EHRs for Administrative and Clinical Use

EHRs can offer several benefits for administrative and clinical use, such as:

– Reducing errors and enhancing patient safety. EHRs can prevent errors such as illegible handwriting, missing information, duplicate tests, or adverse drug events by providing accurate, complete, and up-to-date information about patients. EHRs can also alert providers to potential problems such as allergies, drug interactions, or abnormal test results.
– Improving efficiency and productivity. EHRs can streamline workflows and reduce administrative tasks such as paper-based documentation, filing, faxing, or phone calls. EHRs can also enable faster access to patient information, easier sharing of information among providers and settings, and automated reminders and prompts for preventive care or follow-up.
– Enhancing patient engagement and satisfaction. EHRs can empower patients to access their own health information, communicate with their providers, manage their appointments and prescriptions, and participate in their care plans. EHRs can also improve patient satisfaction by reducing wait times, improving continuity of care, and providing personalized education and feedback.
– Supporting quality improvement and research. EHRs can facilitate quality improvement and research by providing data and tools for measuring performance, identifying gaps in care, implementing best practices, and evaluating outcomes. EHRs can also support research by enabling data collection, analysis, and sharing for clinical trials, epidemiological studies, or comparative effectiveness research.

Challenges of EHRs for Administrative and Clinical Use

Despite the benefits of EHRs for administrative and clinical use, there are also some challenges that need to be addressed, such as:

– Cost and complexity. EHRs can be expensive and complex to implement and maintain, requiring significant investments in hardware, software, training, maintenance, and security. EHRs can also pose technical challenges such as interoperability issues, system failures, or data breaches.
– Usability and workflow. EHRs can affect the usability and workflow of providers and staff, requiring changes in roles, responsibilities, processes, and culture. EHRs can also introduce new sources of errors or dissatisfaction such as poor interface design, data entry burden, alert fatigue, or loss of human interaction.
– Legal and ethical issues. EHRs can raise legal and ethical issues such as privacy, confidentiality, consent, ownership, liability, or malpractice. EHRs can also pose challenges for complying with regulations and standards such as HIPAA (Health Insurance Portability and Accountability Act), HITECH (Health Information Technology for Economic and Clinical Health Act), or Meaningful Use.

Conclusion

EHRs are transforming the delivery of health care by providing digital records of patients’ health information that can improve the quality, safety,
efficiency,
and coordination of care. EHRs can also support administrative
and clinical functions such as billing,
scheduling,
ordering,
prescribing,
reporting,
and research. However,
EHRs also present some challenges that need to be overcome,
such as cost,
complexity,
usability,
workflow,
legal,
and ethical issues. Therefore,
EHRs require careful planning,
implementation,
evaluation,
and improvement to ensure their optimal use
and benefit for health care providers
and patients.

References

– Adler-Milstein J., DesRoches C.M., Kralovec P., et al. Electronic Health Record Adoption In US Hospitals: Progress Continues But Challenges Persist. Health Affairs 2015 – Research Paper Writing Help Service; 34(12): 2174–2180.
– Buntin M.B., Burke M.F., Hoaglin M.C., Blumenthal D. The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results. Health Affairs 2011; 30(3): 464–471.
– Menachemi N., Collum T.H. Benefits And Drawbacks Of Electronic Health Record Systems. Risk Management And Healthcare Policy 2011; 4: 47–55.
– Sittig D.F., Singh H. A New Socio-technical Model For Studying Health Information Technology In Complex Adaptive Healthcare Systems. Quality And Safety In Health Care 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer; 19(Suppl 3): i68–i74.

1. Plan of care, evaluation, subjective data, and objective data are all parts of

A. a telephone encounter.

B. documentation.

C. the progress note.

D. a clinic visit.

2. Mr. Smith has an appointment with Dr. Johnson at 9:00 A.M. for his annual wellness exam. Mrs. Adams calls the clinic first thing in the morning due to fever, chills, and cough for 3 days and is given an appointment at 9:00 A.M. with Dr. Johnson as well. This is an example of

A. overlap.

B. accommodating.

C. jamming.

D. double-booking.

3. A provider performs _______ to signify that everything in the note is correct.

A. technological signature

B. digital signature

C. annotation

D. autograph

4. Dan has made an appointment for review of his medication, as he recently relocated to the area with his family. Before his appointment, he has been asked to fill out and bring _______ form.

A. disclosure

B. health history

C. review of systems

D. consent

5. Incident reports are reviewed by the staff to aid in

A. policies.

B. prevention.

C. change.

D. procedures.

6. Which of the following is an appropriate way to reduce no-show appointments?

A. Ensure the patient writes down their appointment.

B. Perform reminder calls one to two days preceding the appointment.

C. There are no good ways to reduce no-shows.

D. Schedule all appointments within seven days of the appointment day.

7. A patient notes that they smoke a half a pack of cigarettes per day and drink a six pack of beer every night. Where would this be documented in the chart?

A. Medical history

B. Social history

C. Chief complaint

D. Problem list

8. Which of the following is not considered an integrated device?

A. Telephone

B. Signature pad

C. Scanners

D. Camera

9. _______ allows for disclosure of protected health information (PHI) through phone, fax, or email without specific patient authorization.

A. Confidentiality

B. HIPAA Security Rule

C. HIPAA Privacy Rule

D. Clinic policies and procedures

10. _______ is the most important responsibility of all members of the medical office.

A. Communication

B. Accountability

C. Documentation

D. Punctuality

11. All of the following require an incident report to be filed except

A. if the wrong patient is contacted for an appointment reminder.

B. if the employee suffers a needle stick.

C. if the wrong medication is administered to the patient.

D. if the patient falls in the hallway.

12. The process of a data code being unreadable until its destination is reach is called

A. cryptic.

B. jumble.

C. decryption.

D. encryption.

13. The _______ is a centralized location for a summary of a patient’s acute and chronic conditions.

A. chief complaint

B. medical history

C. disease list

D. problem list

14. Which of the following are not guidelines for proper telephone etiquette?

A. Answer by the third ring is possible

B. Answer with a pleasant greeting

C. Speak slowly and clearly

D. Keep a straight, professional face

15. Myrtle uses a cane to ambulate. She came to the clinic for an appointment, but before making it inside the building she tripped and fell on the curb. What type of document needs to be created?

A. Incident report

B. Fall report

C. Accident report

D. Injury report

16. Through the use of _______ a patient may view open appointments or schedule their own appointment.

A. patient access

B. patient flow

C. patient gateway

D. patient portal

17. Cindy has a hand-written fax number from a patient’s parent to fax a note to the school for use of a medication while at school. Cindy is unable to read all of the fax numbers. What should she do?

A. Avoid sending the note since the correct number wasn’t given

B. Call the patient to confirm the number

C. Send to the closest number

D. Ask other office staff

18. What’s the default landing page in SCMO when entering a patient encounter?

A. Allergies

B. Chief complaint

C. Vital signs

D. Progress note

19. _______ is a rundown of organ systems that can be used to pinpoint certain concerns or unusual findings.

End of exam

A. Review of systems

B. Report of symptoms

C. Report of systems

D. Review of symptoms

20. “It feels like an ice pick in my head” and “I’m coughing up a lung” are considered

A. chief complaints.

B. reason for visit.

C. presenting symptom.

D. medical concerns.

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