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EHR link 2 ch 3 & 4
| Question | Answer |
|---|---|
| rules and standards of conduct that govern professional behavior and arise from our shared understanding of morality is known as | ethics |
| formal, enforceable rules and policies based on community standards of conduct are known as | laws |
| the patient's right, which exists to varying degrees, to have private health data collected in a way that can never be linked or traced back to him is known as | anonymity |
| the patient's right and expectation that individually identifiable health information will be kept private and not disclosed without the patient's permission, and is limited or protected by law to varying degrees is known as | confidentiality |
| a decision by an insurance company, such as a health or disability insurer, to deny or terminate insurance or to increase rates, usually based on information obtained from a consumer reporting agency is known as | adverse action |
| giving access to, releasing, or transferring information to a person or entity not legally or ethically authorized to use or have knowledge of it is known as | disclosure |
| permission given to a covered entity for uses and disclosures of protected health information for treatment, payment, and healthcare operations is known as | consent |
| health information that clearly identifies an individual patient or could reasonably be used to identify the patient is known as | individually identifiable health information (IIHI) |
| individually identifiable health information that is stored, maintained, or transmitted electronically; in practice, however, this term is often used interchangeably with the term IIHI, regardless of what form the information takes is known as | protected health information (PHI) |
| the process of determining weather the person attempting to access a given network or EHR system is authorized to do so. it can include password entry or use of biometric data or smart cares is known as | authentication |
| a document giving a covered entity permission to use protected health information for specified purposes other than treatment, payment, or healthcare operations or to disclose protected health information to a third party specified by the patient is | authorization |
| an agency regulated by the federal trade commission under fair credit reporting that sells or cooperatively exchanges consumer information and history in areas such as credit and healthcare is known as | consumer reporting agency |
| measures taken to prevent interference with computer network operations and to avert security breaches involving the unauthorized use, disclosure, modification, erasure, or destruction of protected health information | safeguards |
| healthcare providers, health plans, and healthcare clearinghouse that transmit claims electronically are called | covered entities |
| a key provision of the HIPPA privacy rule requiring that disclosures include no more than the minimum necessary amount of information to accomplish a gicen purpose is known as | minium necessary standard |
| a use for a prescripition durg other than that for which the food and drug administation has approved it is known as | off-lable indication |
| the patients freedom to determin when, how much, and under what circumstances his medical information may be disclosed is called the patients | privacy |
| a use of health information that is not directly related to patient care. such uses include statistical analysis, research, quality and safety assurance processes, public health monitoring, payment, provider certification or accreditation, and marketing | secondary use |
| the medical office must assess threats to the confidentiality, integrity, and availability of PHI is what safeguard | risk analysis |
| the practice should put security measures in place in order to minimize risks to a level that can be managed effectively. doing so requires stron leadership and good communication known as | risk management |
| the practice must determine before any infraction occurs what the penalties will be for staff members who fail to comply with security measures is known as what safeguard | sanction (penalties) policy |
| the office should construct a procedure to review its compliance procedures periodically in which policies can be revised to shore up any weakmesses in what security safegard | information system activity review |
| a record that a user's electronic footsteps by recording activity and transations, including unsuccessful attempts to view unauthorized screens, within the EHR system is known as an | audit trail |
| the shared set of values, beliefs, and assumptions that govern the perceptions and interactions of the organization's members and guides their behavior and decision making is known as | organizational cluture |
| the process of training the staff and gathering the resources necessary to implement a conversion from a paper-based or legacy EHR to a new EHR system; the preperation phase that occurs before the go-live date is known as | pre-implementation process |
| the systematic control of patient records, from creation through maintenance and storage is known as | records management |
| a medical office in which health records are stored and accessed in various formats like paper chats, EHR's, and perhaps microfilm, microfiche, or other media is known as | hybrid |
| a formal written request sent to a shortlist of software vendors outlining the practice's needs, resources, time frame, and budget, and requesting specific information abour customer support, software features and proposed platform is known as | request for proposal (RFP) |
| a functional EHR slated to be replaced with newer software is called | legacy |
| to become operational; the point at which the offline practice mode ends and a real-world, online use begins is known as | go live |
| a company that provides online access to a software application requires a licensing agreement with the end-user. this agreement allows the end-user to access software over the internet and can be a less expensive alternative is known as | application service provider (ASP) |
| RFP | request for proposal |
| a program or suite of programs with word processing, graphics, satabase, spreadsheet, or other capabilities that is used to accomplish work-related tasks for the user is known as | applications software |
| copying and pasting notes from a patient's previous visit into the current progress note or pasting notes from one patient's record into the record of a patient with a similar diagnosis and presentation is known as | cloning |
| the process of indirectly entering data into a system by recording it electronically and converting it to machine-readable form such as bar coding, voice recognition software, and structured templates is known as | data capture |
| a standardized list of preferred terms for medical diagnoses, findings, procedures, services, and treatment, along with machine-readable numeric codes that identify them such as ICD, CPT, and NDC is known as | controlled vocabulary |
| use of mouse-clicks, touch-screen commands, or simple keystroke combinations to enter data that conform to a controlled vocabulary; it healps practitioners imput a large amount of info efficiently and is appropriate for describing typical findings called | structured data entry |
| ASP | application service provider |
| VPN | virtual private network |
| a powerful central computer serves a network of connected PCs in which the interface that allows the client and server to communicate resides on the client's computer. the software stores files on the server and shares them when reseived by the client | client-server model |
| predifined, customizable forms that facilitate structured data collection by offering the clinician a set of menus, check boxes, and other tools with which to enter data into progress notes, letters, and ther EHR documents is called a | template |
| free data entry using direct keying, dictation, or transcription; unstructured data entry is needed to describe nuanced patient presentations and unique individual health histories is known as | unstructured data entry |
| a pathway that allows encrypted data to travel securely through an internet connection to its destination, where it is unencrypted is called | virtual private network |
| a set of related tasks necessary to complete a step in a business process is called | workflow |
| a program that displays moving text or images on the screen if input (keystroke) is not received for a given time period is called | screensaver |
| a set of patient centered tools embedded within EHR that can be used to improve patient safety, ensure that care conforms to published protocol for specific conditons, and reduce duplicate or unnecessary care and its associated cost is known as | clinical decision support (CDS) |
Created by:
maryce
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