NHA CEHRS Practice Questions with Correct
Answers
EHR
electronic health record - accessible to providers and other staff with login credentials
regardless of location.
medical record number
A set of numbers used to identify a patient and associated recorded health data
Notice of Privacy Practices (NPP)
Document required by law to inform a patient how the organization will use their health care
information
advance directives
A legal document designed to indicate a person's treatment choices when they are unable to
make health care decisions
Assignment of Benefits (AOB)
Form that authorizes health insurance benefits to be sent directly to providers.
Computerized provider order entry (CPOE)
Use of computer system to enter and process prescriptions and treatments at the point of care
Electronic medication administration record (eMAR)
An electronic record containing a patient's prescribed medications, administration times, and
who administered it.
Evaluation and Management (E/M Codes)
Used to bill for services based on assessed findings documented in the visit note
7 components of E&M
History, examination, medical decision making, counseling, coordination of care, nature of
presenting problem, time
,personal health record (PHR)
Promotes patient engagement in managing health and conditions
T/F Kiosks are part of a fully integrated ehr model
True
Universal Medical Device Nomenclature System (UMDNS)
Provides standard terminology for medical devices
CPOE
computerized physician order entry
Clinical Decision Support System (CDSS)
A program designed to prompt providers with clinical decisions
Protected Health Information (PHI)
Health information specific to a patient
Covered Entity
A health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health
information
What is considered protected health information?
Name, age, sex, address, demographic information, account information, social status,
clinical status
2 instances when disclosure of PHI is mandatory
1. When patient or legal representative requests it.
2. Part of investigation by DHHS
Regarding PHI, patients have the right to:
1. Receive explanation of privacy practices
2. Request restrictions on disclosure
3. Specify how they receive confidential communication
, 4. Inspect or obtain copy of health record
5. Request amendment of inaccurate records
When can organizations use/share PHI without specific authorization?
1. Treatment - like consulting between providers
2. Payment - contacting insurance
3. Health care operations - chart reviews and audits
Privacy Rule allows for:
Incidental disclosures (minor like hearing a name in a waiting room), public interest (data on
vaccines, dangers to public)
Minimum necessary concept
Protecting private health information by limiting access based on need.
Encryption
Process of converting readable data into code only intended recipients can read.
data safeguards
1. Risk analysis and management
2. Physical safeguards (limiting access to work areas)
3. Technical safeguards (like passwords)
4. Administrative safeguards (designated employees responsible for things)
5. Policies and procedures
chief complaint
the main reason for the patient's visit
Subjective Elements
summary of what the patient tells the clinic staff about history, family, family history,
problems, concerns, symptoms & goals
review of systems
Answers
EHR
electronic health record - accessible to providers and other staff with login credentials
regardless of location.
medical record number
A set of numbers used to identify a patient and associated recorded health data
Notice of Privacy Practices (NPP)
Document required by law to inform a patient how the organization will use their health care
information
advance directives
A legal document designed to indicate a person's treatment choices when they are unable to
make health care decisions
Assignment of Benefits (AOB)
Form that authorizes health insurance benefits to be sent directly to providers.
Computerized provider order entry (CPOE)
Use of computer system to enter and process prescriptions and treatments at the point of care
Electronic medication administration record (eMAR)
An electronic record containing a patient's prescribed medications, administration times, and
who administered it.
Evaluation and Management (E/M Codes)
Used to bill for services based on assessed findings documented in the visit note
7 components of E&M
History, examination, medical decision making, counseling, coordination of care, nature of
presenting problem, time
,personal health record (PHR)
Promotes patient engagement in managing health and conditions
T/F Kiosks are part of a fully integrated ehr model
True
Universal Medical Device Nomenclature System (UMDNS)
Provides standard terminology for medical devices
CPOE
computerized physician order entry
Clinical Decision Support System (CDSS)
A program designed to prompt providers with clinical decisions
Protected Health Information (PHI)
Health information specific to a patient
Covered Entity
A health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health
information
What is considered protected health information?
Name, age, sex, address, demographic information, account information, social status,
clinical status
2 instances when disclosure of PHI is mandatory
1. When patient or legal representative requests it.
2. Part of investigation by DHHS
Regarding PHI, patients have the right to:
1. Receive explanation of privacy practices
2. Request restrictions on disclosure
3. Specify how they receive confidential communication
, 4. Inspect or obtain copy of health record
5. Request amendment of inaccurate records
When can organizations use/share PHI without specific authorization?
1. Treatment - like consulting between providers
2. Payment - contacting insurance
3. Health care operations - chart reviews and audits
Privacy Rule allows for:
Incidental disclosures (minor like hearing a name in a waiting room), public interest (data on
vaccines, dangers to public)
Minimum necessary concept
Protecting private health information by limiting access based on need.
Encryption
Process of converting readable data into code only intended recipients can read.
data safeguards
1. Risk analysis and management
2. Physical safeguards (limiting access to work areas)
3. Technical safeguards (like passwords)
4. Administrative safeguards (designated employees responsible for things)
5. Policies and procedures
chief complaint
the main reason for the patient's visit
Subjective Elements
summary of what the patient tells the clinic staff about history, family, family history,
problems, concerns, symptoms & goals
review of systems
