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pg. 1 NHA - Certified Electronic Health Record Specialist (CEHRS) Study Guide AVTEC Newest 2025| Complete 150 Actual Questions and Correct Detailed Answers (Verified Answers) Graded A+|| New!!
Electronic Health Record (EHR) - ANSWER - While this term is generic, its use denotes a system-wide record that involves inputs from many systems and is used across a diverse environment of care with multiple location; although not strictly defined as such, EHR often refers to the electronic records in a hospital or integrated health care delivery system.
EHR technology - ANSWER - Refers to the conceptual EHR, including the basic structure, functionality, and expected outcomes users expect from any system identified as being an electronic health or medical records system.
Electronic Medical Record (EMR) - ANSWER - Another generic term for a digitized medical record; this term has evolved to most often refer to the single, standalone records systems that providers' offices and other smaller outpatient settings use; the term EMR is most often used in reference to the electronic records used by providers in their private practice and outpatient settings; many EMR's can exchange data with larger hospital-based EHR systems through the use of a Continuity of Care Document (CCD)
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pg. 2 Fully-integrated EHR - ANSWER - Functionality that has replaced paper records entirely; few hospitals or health care systems in the U.S.have achieved this yet, but many are moving in this direction.
Health Information Management (HIM) department - ANSWER - Department responsible for the care and management of all patient information; as electronic records began to replace paper-based records, HIM professionals became key players in the transition to the EHR or EMR system; previously known as the medical records department.
Health Information Technology - ANSWER - General use of computers and related devices to manage the day-to-day functions in a health care environment.
Health Insurance Portability and Accountability ACT of 1996 (HIPAA) - ANSWER - Addressing security and privacy protections for health care information.
HIPAA Privacy Rule - ANSWER - Mandates the protection of patients' personal health information by hospitals and health care facilities.
HIPAA Security Rule - ANSWER - Sets forth the administrative, physical, and technical safeguards for covered entities in order to protect the confidentiality, integrity, and availability of PHI that is stored electronically.
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pg. 3 History and Physical (H and P) - ANSWER - Providers document a patient's history and perform a physical exam when she presents for health care services.
Health Information Technology for Economic and Clinical Health (HITECH) - ANSWER - Encourages the adoption and meaningful use of health information technology.
Hospital Information System (HIS) - ANSWER - Collection of systems that collect, store, and allow manipulation and management of data generated in the daily operations of a facility.
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - ANSWER - Coding and classification system that groups diseases, disorders, and procedures into similar categories; there are three volumes in ICD-9-CM.
Information Technology (IT) Department - ANSWER - The IT department in facilities has emerged as a necessary response to the transition from a paper-based world to one that increasingly reliant on technology.
Joint Commission on the Accreditation of Health Care Organizations - ANSWER - Not-for-profit and independent (non-governmental) organization that accredits and certifies more than 19,000 health care facilities and programs in the U.S.
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