Electronic Health Records Flashcards
7 cards from real RMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Electronic Health Records flashcards as text
What does the term 'interoperability' refer to in an EHR system?
Answer: The ability of different systems to exchange and use patient data
Interoperability is the capacity of different EHR systems to exchange, interpret, and use shared patient data.
A patient requests an amendment to incorrect information in their EHR. What is the correct action?
Answer: Add an addendum noting the correction without erasing the original
Corrections are made via an addendum so the original entry and audit trail remain intact.
Which feature in an EHR alerts a provider that a prescribed drug conflicts with a patient's current medication?
Answer: Clinical decision support
Clinical decision support tools flag drug interactions, allergies, and other safety concerns.
What is the primary purpose of an audit trail in an EHR?
Answer: To track who accessed or modified a record and when
An audit trail logs user access and changes, supporting security and accountability.
A medical assistant notices a colleague accessing the chart of a celebrity not under their care. This is a violation of which principle?
Answer: Minimum necessary access
HIPAA's minimum necessary rule limits access to only the information needed to perform one's duties.
What does CPOE stand for in the context of EHRs?
Answer: Computerized Provider Order Entry
CPOE allows providers to enter medical orders directly into the electronic system, reducing transcription errors.
Which of the following is a benefit of using structured data fields rather than free text in an EHR?
Answer: Easier data reporting and analytics
Structured fields standardize entries, making data easier to search, report, and analyze.