Definitions
The expectation that information shared with a healthcare provider will be used only for its intended purpose
What is confidentiality
CPOE
what is Clinical Provider Order Entry
HIPAA mandates that all EHRs have ______ these trails are monitored for potential security breaches
What are audit trails?
How many core competencies must be met to receive incentive payments?
What is 15
What can cause errors in paper records?
What is illegible handwriting, misplaced decimals, and abbreviations
Data that have been manipulated into something meaningful
What is information
LIS
What is Laboratory Information System
The computer notified me that a user accessed the PHI of a patient who is a celebrity. This is an example of a ____
What is a trigger
To gain payment through HITECH, practitioners must demonstrate ______ use of a _____ EHR.
What is meaningful use of a certified EHR.
Data that can be easily extracted from EHR, easily searched, retrieved, aggregated and summarized for easy interpretation in a standardized report
What is coded data
A _______ collects and stores medical, nursing, clinical ancillary area, and therapy department information related to patient care.
What is Clinical Information System
POC
What is Point Of Care
What is 60 days?
HITECH act was passed as part of the ____
what is ARRA American Recovery and reinvestment act
Information entered in a pre-determined filed within a record, file or note
What is structured data
_______ system can be used by any healthcare profession tp collect and store patient assessments, progress notes, and care plans. This includes nurses, physicians, physical therapists, pharmacists, dieticians, etc.
What is interdisciplinary charting system
a device used at the point of care, a wireless computer mounted on a mobile cart that can be moved from patient to patient
What is COW
A HIPAA violation due to willful neglect but the violation is corrected within the required period of time- What is the penalty?
what is $10,000/ violation, annual max of $250,000, for repeat violations $50,000 per violation with a max of $1.5 Million.
What does HITECH stand for?
What is Health Information Technology for Economic and Clinical Health ACT
what are "the brains" of an EHR, and what can it do?
What is Clinical decision support.
Examples include medication error alerts, reference materials, flagging abnormal lab values, trend analysis, and health maintenance reminders.
This type of data needs to be codified or the meaning is ambiguous
Fielded data (terms that can be used o describe the same symptom, condition or observation.
HIE
What is health information exchange
What year was HIPAA passed, and what does it stand for?
The Health Information Portability and Accountability Act of 1996.
what mandates meaningful use regulations and mandates health information exchange functionality and its use?
What is HITECH legislation
One of the major challenges of building a computer based patient record is the amount of _____ in a health record.
What i free text data