EHR Ch 1-6 54 Quiz Questions
Correctly Solved
A hanging protocol refers to the number of images that simultaneously
display on the radiologist's monitor.
Radiology Reports - ✔ ✔ Usually dictated by the radiologist and
typed by a medical transcriptionist, although some use speech
recognition software that converts it into a typed report.
Radiology reports are seldom available as a codified EHR record.
Radiology observations that are codified are those related to the size
and stage of tumors
Medication Orders - ✔ ✔ Efforts to increase safety by hospitals
include:
CPOE
Computerizing the pharmacy
Positive identification systems to correctly match the medication with
the patient.
A pharmacy benefit manager
An intermediary company that electronically checks the patient's
formulary for the pharmacy system
Electronic prescriptions - ✔ ✔ Prescription is issued and recorded in
one step.
,Any problems with the prescription can be corrected immediately
before being sent.
Prescriptions are transmitted electronically to the pharmacy.
Medication errors due to handwriting are reduced
Closed loop process for med safety - ✔ ✔ Clinician writes
prescription using CPOE.
Prescription is checked and approved b y the pharmacist.
Nurse receives order electronically and removes vial from medication-
dispensing system.
A handheld scanner device is used to read a barcode on the patient's
armband to be sure the medication is being given to the right patient.
Nurse scans the barcodes on each medication or intravenous solution
and the computer program checks the electronic order and warns the
nurse of any discrepancies.
Nurse administers the medication to the patient
Nurse documents the patient's chart. (Some systems repeat scan the
armband, or scan the nurses badge to complete documentation
electronically
The 5 rights of medication administration - ✔ ✔ 1 Right patient
, 2 Right time and frequency
3 Right medication
4 Right dose
5 Right route of administration
WHO - ✔ ✔ WORLD HEALTH ORGANIZATION
ICD-9-cm 1900-1979 - ✔ ✔ International Classification of Diseases,
9th Revision, Clinical Modification
Three volumes:
Volumes 1 and 2 provide a listing and an index of diagnosis codes.
Volume 3 lists codes for hospital inpatient procedures.
Code consists of three characters, a decimal point, and up to two
numerals.
First three letters represent primary diagnosis.
The ending numerals further refine the diagnosis specificity
Insurance Billing - ✔ ✔ In 1989, the ICD-9-CM codes became
required for insurance carriers to process claims.
Correctly Solved
A hanging protocol refers to the number of images that simultaneously
display on the radiologist's monitor.
Radiology Reports - ✔ ✔ Usually dictated by the radiologist and
typed by a medical transcriptionist, although some use speech
recognition software that converts it into a typed report.
Radiology reports are seldom available as a codified EHR record.
Radiology observations that are codified are those related to the size
and stage of tumors
Medication Orders - ✔ ✔ Efforts to increase safety by hospitals
include:
CPOE
Computerizing the pharmacy
Positive identification systems to correctly match the medication with
the patient.
A pharmacy benefit manager
An intermediary company that electronically checks the patient's
formulary for the pharmacy system
Electronic prescriptions - ✔ ✔ Prescription is issued and recorded in
one step.
,Any problems with the prescription can be corrected immediately
before being sent.
Prescriptions are transmitted electronically to the pharmacy.
Medication errors due to handwriting are reduced
Closed loop process for med safety - ✔ ✔ Clinician writes
prescription using CPOE.
Prescription is checked and approved b y the pharmacist.
Nurse receives order electronically and removes vial from medication-
dispensing system.
A handheld scanner device is used to read a barcode on the patient's
armband to be sure the medication is being given to the right patient.
Nurse scans the barcodes on each medication or intravenous solution
and the computer program checks the electronic order and warns the
nurse of any discrepancies.
Nurse administers the medication to the patient
Nurse documents the patient's chart. (Some systems repeat scan the
armband, or scan the nurses badge to complete documentation
electronically
The 5 rights of medication administration - ✔ ✔ 1 Right patient
, 2 Right time and frequency
3 Right medication
4 Right dose
5 Right route of administration
WHO - ✔ ✔ WORLD HEALTH ORGANIZATION
ICD-9-cm 1900-1979 - ✔ ✔ International Classification of Diseases,
9th Revision, Clinical Modification
Three volumes:
Volumes 1 and 2 provide a listing and an index of diagnosis codes.
Volume 3 lists codes for hospital inpatient procedures.
Code consists of three characters, a decimal point, and up to two
numerals.
First three letters represent primary diagnosis.
The ending numerals further refine the diagnosis specificity
Insurance Billing - ✔ ✔ In 1989, the ICD-9-CM codes became
required for insurance carriers to process claims.
