INTRODUCTION ACMA TEST WITH
COMPLETE SOLUTIONS
Key Terminology for Electronic Record Keeping - ANSWER-
- ANSWER-Electronic Medical Records (EMR) are computerized records of one
physician's encounter with a patient over time. The EMR reflects treatment of a patient
by one physician.
- ANSWER-Electronic Health Record (EHR) reflects the data from all sources that have
treated the individual.
- ANSWER-Personal Health Record (PHR) are maintained and owned by the patient.
The patient makes the decision whether to share the contents with their physician.
- ANSWER-Acute care, most often refers to a hospital, treats patients with urgent
problems that cannot be handled.
- ANSWER-Ambulatory care refers to treatment without admission to hospital.
- ANSWER-Clinical templates allow doctors to document patient encounters into an
EHR on a structured form.
- ANSWER-RADT refers to registration, admissions, discharge and transfer
- ANSWER-UPI is the unique patient identifier links all clinical observations, tests,
procedures, complaints, evaluations, and diagnoses to the patient.
- ANSWER-DATA may be structured or unstructured. Unstructured data could be a
dictated report, a written progress note, or voice files et.al. Structured data is standard
templates, bar codes and numeric codes et. al.
- ANSWER-Decision support software is used to access current information about a
disease or condition. Used by physicians.
- ANSWER-Voice Recognition software translates what a provider is saying and types
those words into text.
- ANSWER-Master Patient (person) Index (MPI) is where patients are listed/entered
only once and allows for documentation of each visit.
- ANSWER-Button an element of the user interface on which the user can click to
execute a command such as confirm, cancel or exit
COMPLETE SOLUTIONS
Key Terminology for Electronic Record Keeping - ANSWER-
- ANSWER-Electronic Medical Records (EMR) are computerized records of one
physician's encounter with a patient over time. The EMR reflects treatment of a patient
by one physician.
- ANSWER-Electronic Health Record (EHR) reflects the data from all sources that have
treated the individual.
- ANSWER-Personal Health Record (PHR) are maintained and owned by the patient.
The patient makes the decision whether to share the contents with their physician.
- ANSWER-Acute care, most often refers to a hospital, treats patients with urgent
problems that cannot be handled.
- ANSWER-Ambulatory care refers to treatment without admission to hospital.
- ANSWER-Clinical templates allow doctors to document patient encounters into an
EHR on a structured form.
- ANSWER-RADT refers to registration, admissions, discharge and transfer
- ANSWER-UPI is the unique patient identifier links all clinical observations, tests,
procedures, complaints, evaluations, and diagnoses to the patient.
- ANSWER-DATA may be structured or unstructured. Unstructured data could be a
dictated report, a written progress note, or voice files et.al. Structured data is standard
templates, bar codes and numeric codes et. al.
- ANSWER-Decision support software is used to access current information about a
disease or condition. Used by physicians.
- ANSWER-Voice Recognition software translates what a provider is saying and types
those words into text.
- ANSWER-Master Patient (person) Index (MPI) is where patients are listed/entered
only once and allows for documentation of each visit.
- ANSWER-Button an element of the user interface on which the user can click to
execute a command such as confirm, cancel or exit
