Private information network that is similar to the Internet in that it uses internet technologies ( hosts policies and procedures, forms, events,etc)
What is the Intranet?
Designed for orders to be entered by the healthcare providers.
What is the Computerized Provider Order Entry (CPOE)?
A cross between free text and unstructured data entry.
What is template - based data entry?
The expectation that information shared with a healthcare provider will be used only for it's intended purpose.
What is confidentiality?
Examples include simple language, eye contact, nodding head, engaging with patient, showing medications and allergies, strategically placing monitor so you can look at patient and screen.
What is proper etiquette when interviewing and entering data in to the computer?
The "brains" of the computer. Also known as a microprocessor.
What is the CPU?
Established in 2004 within the Office of the Secretary for HHS to serve as a resource to the entire healthcare system, to support HIT adoption,and to promote a nationwide health information exchange. It's goal is to improve healthcare in the United States.
What is the ONC ( Office of the National Coordinator for Health Information Technology)?
The process of recording healthcare - related data in a health record system or clinical database.
What is data capture?
Utilizes one level of access controls such as a username and password.
What is one-factor authentication?
Examples include physicians, nursing staff, social services, case management, pharmacology, radiology, respiratory care.
What are the other members of the healthcare team?
Raw facts and figures.
What is data?
An Act which was part of the stimulus package President Obama passed in 2009 known as the ARRA ( American Recovery and Reinvestment Act).
What is the HITECH Act?
The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts.
What is the clinical decision support (CDS) system?
Individually identifiable health information that is transmitted or maintained in any form or format by an organization subject to HIPPA.
What is PHI (protected health information)?
Documentation should always address these questions.
What are "who, what, where, when, how, why?"
Has a central processing unit (CPU), computer memory, and storage devices for data.
What is a PC?
Computer programs focused on fiscal management for processing insurance claims and patient statements.
What are practice management systems ( PMSs)?
These use data elements that allow for free text entry, which means that the user can type in any data that he or she chooses.
What are unstructured data fields?
A federal law that impacts many areas of healthcare , including insurance portability, code sets, privacy, security, electronic data interchange (EDI), and national identifier standards.
What is HIPPA ( Health Insurance Portability and Accountability Act of 1996).
Best type of communication that does not require immediate feedback
What is an email?
Large computers that are used by the government and other organizations that require speed and the ability to process large amounts of data.
What are Mainframe computers?
Records all medications (the dosages,route of administration, time med was given, who gave the medication).
What is the EMAR? (Electronic Medication Administration Record)
Guide the user during the data entry process, limiting what a user can enter into the field.
What are Structured Data Fields?
A health plan, healthcare clearinghouse, or healthcare provider that transmits any health information in electronic form for one of the covered transactions.
What is a covered entity (CE)?
List the four components of the SOAP format
What are 1) Subjective 2) Objective 3) Assessment 4) Plan?