The Electronic Health Record – Test

Which of the following would be documented using computerized provider order entry (CPOE)?
A. E-prescribing
B. Appointment book
C. Patient correspondence
D. Patient ledger
E. Email correspondence

A legal document that may include a “do not resuscitate order” would be called:
A. Patient information sheet
B. Living Will
C. HIPAA form
D. Informed consent forms
E. H&P

_________allows practitioners to tailor the care of an individual patient by making sure it adheres to published guidelines for the patient’s specific diagnoses.
A. CDS
B. HIPAA
C. Administrative processes core function
D. Patient support function
E. Patient education templates

The implementation of an electronic health record A. Trueincreases patient satisfaction for the medical office.
A. True
B. False

Introducing the electronic health record into the doctor’s office will result in little to no employee resistance.
A. True
B. False

Power outages, viruses, backup procedures, and computer freezes and crashes pose other safety and security concerns for medical offices using EHRs
A. True
B. False

The doctor prescribes the patient an antibiotic for a URI. It is sent directly to the patient’s pharmacy. The pharmacist notices the patient is allergic to this medication and informs the doctor. This is an example of which core function?
A. Patient support
B. Administrative processes
C. Orders management
D. Decision support
E. Health information management

Patient information:
A. is protected by law
B. In the record is health related data only
C. May be documented by the medical assistant into the patient chart
D. Documented in the chart is not considered to be a legal document

A fixed amount of money a patient is contracted to pay out of pocket at each visit is called:
A. Deductible
B. Patient payment
C. Copayment
D. Coinsurance
E. Self-pay portion

What is the difference between the EHR and EMR?

Geraldine has been referred to a cardiologist for a MVP. The EHR allows the specialist to gain access to Geraldine’s relevant heart history with her permission. This is an example of which core function?
A. Patient support
B. Administrative processes
C. Health information and data management
D. Electronic communication and connectivity
E. Decision support

List the eight core functions of a certified EHR technology.

. The doctor asks the medical assistant to print a handout on hypertension for a patient to take home. This is an example of which EHR core function?
A. Patient support
B. Administrative processes
C. Population health
D. Decision support
E. Order management

An established patient is one who has been seen by a member of the healthcare team within the last 4 years
A. True
B. False

Which of the following is NOT found in the patient medical record?
A. Immunization records
B. Operative reports
C. Living Will
D. College transcripts
E. Referral letters

The medical assistant is a frequent documenter of the patient record.
A. True
B. False

Maintaining patient records is optional for healthcare providers.
A. True
B. False

Which of the following is NOT a documenter of the patient chart?
A. Physician
B. Patient
C. Medical assistant
D. Medical billing specialist
E. All are documenters Incorrect

Which of the following sets standards for what each software system should be able to accomplish?
A. HIPAA Incorrect
B. CMS
C. OIG
D. CCHIT
E. CDC

Skills for using the EHRs include:
A. Knowledge of medical terminology
B. Math skills
C. Empathy
D. Flexibility
E. Setting priorities

Which of the following would most likely affect EHR user satisfaction?
A. Ease of making mistakes
B. Cost of implementation Incorrect
C. Short training period
D. Security issues
E. Improved patient quality of care

List 4 types of administrative functions in the EHR.

The amount of time records must be kept in storage by a medical office:
A. Restore
B. Retention
C. Statute of limitations
D. Limitation period
E. None of the above

Which of the following is NOT an example of Student Resources in SimChart for the Medical Office?
A. Submitting an Assignment
B. Gradebook Overview
C. Job Readiness Incorrect
D. Assignment Answer Key

When the user enters the Electronic Health Record , the landing page is:
A. Calendar view
B. Patient dashboard
C. Patient ledger
D. Gradebook
E. Patient search Incorrect

The actions completed in the Playground:
A. Cannot be saved
B. Are graded automatically
C. Are not recorded by the system for the instructor
D. Can be viewed only by the student
E. Are not linked to the Assignment grid

What is a preselected value or setting that will be used unless the user specifies a substitute by overriding the preselected choice?
A. Default
B. Context-specific feature
C. Button
D. Icon
E. Radio button

How is entering a new patient in SimChart for the Medical Office performed?
A. Using the Find Patient link
B. In the patient dashboard
C. Searching the patient demographics
D. in the billing module

Front Office, Clinical Care, and Billing and Coding are known as:
A. modules
B. offices
C. Clinic Status
D. tabs
E. Available Functions

Medical assistants who are comfortable with technology are in great demand, often commanding higher salaries and landing positions in the most desirable practices.
A. True
B. False

List some of the clinical information found in the patient chart.

What would the record of a patient who has not been seen by the provider in 3 or more years be considered?
A. New patient
B. Closed record
C. Terminated record
D. Inactive record
E. Pulled record

What is a group of current patients in the electronic health records called?
A. Active patients
B. Patient registry
C. Master patient index
D. Both B & C

SimChart for the Medical Office is a Web-based system that allows the user to access anywhere the Internet is available.
A. True
B. False

What is the landing page for SimChart for the Medical Office known as?
A. Screen ID
B. Assignment screen
C. Patient dashboard
D. Billing and Coding Module

In order to submit an assignment for grading, the user must complete the Electronic Health Record case study and take the quiz.
A. True
B. False

Blue “Add” buttons are used throughout the SimChart for the Medical Office system to make changes to patient accounts.
A. True
B. False

In SimChart for the Medical Office, when the user selects the Clinical Care module, they will be prompted to:
A. Log out of the system
B. Select Add Patient
C. Perform a patient search
D. Add an appointment

What is a security feature that allows you to leave for a few minutes without exposing patients’ information to the risk of unauthorized access?
A. Dashboard
B. Park
C. Screen Saver
D. Login Screen Incorrect
E. Maintenance Icon

You need only enter one patient account for access in all three modules, Front Office, Clinical Care, and Billing Modules
A. True
B. False

HIPAA focuses on protecting privacy and security concerns only.
A. True
B. False

Confidential and anonymous have the same meaning.
A. True
B. False

_____ are a set of rules and standards of conduct that grow from our understanding of right or wrong.
A. Ethics
B. Laws
C. Morals
D. Values
E. Scope of treatment

Dawn was asked to sign a(n) _______ before receiving her flu shot.
A. Authorization
B. Consent
C. Release
D. Contract
E. All of the above

. The office manager reviews the staff____________ every 6 months to determine if any unauthorized information was accessed.
A. Authentication trails
B. Authorization checks
C. User name verification
D. Audit check
E. Audit trail

What does protected health information pertain to?
A. Health information stored and transmitted electronically
B. Health information stored on paper or electronically
C. Protection of conversions that hold personal information
D. The process of releasing paper-based patient records
E. Any of the above

Employees are generally assigned the same privileges as the physician.
A. True
B. False

Encryption and decryption technology are examples of:
A. Administrative safeguard
B. Physical safeguard
C. Technical safeguard
D. Privacy rule
E. All of the above

The Privacy Rule prohibits the discussion of patient information in the following areas except:
A. Elevators
B. Reception areas
C. Over the telephone
D. At the cashier’s window
E. All are prohibited

A patient insurance form is an example of:
A. IIHI
B. HPI
C. PHI
D. All of the above
E. Both A & C only

Security guards are an example of:
A. Administrative safeguard
B. Physical safeguard
C. Technical safeguard
D. Privacy rule
E. All of the above

Medical offices submitting claims electronically are called:
A. HIPAA entities
B. Electronic carriers
C. Covered entities
D. Covered claims
E. HIPAA contracted offices

Implementation of user names, passwords and screen savers are examples of _______.
A. Protected health information
B. Privacy
C. Safeguards
D. Codes
E. Audits

After Kevin’s HIV results are in, the doctor asks him to make an appointment to review the results together in a private office setting. This is an example of:
A. Consent
B. Anonymity
C. Confidentially
D. Privacy
E. Security

The Privacy Rule requires providers to do all of the following except:
A. Post a notice of privacy practices on the wall of the reception area for the public
B. Designate a privacy officer
C. Offer authorization forms for the release of PHI
D. Develop procedures to fix EHR information found to be in error
E. Train staff members of the policies of HIPAA

An office that uses EHR for new patients and paper-based records for established patients is termed:
A. Legacy electronic health record
B. Combination office
C. Hybrid
D. Transitioning office
E. Modified hybrid office

Which of the following is a Core Objective added to the Stage 2 Meaningful Use requirements?
A. Use of secure electronic messaging to communicate with patients
B. Provide clinical summaries for patient at each office visit.
C. Document smoking status
D. Incorporate clinical lab-test results into EHR as structured data

A __________ is a set of related tasks needed to complete a step in a business process.
A. Work list
B. Workflow
C. Job duties
D. Priority list
E. Work production quota

Which of the following is NOT criteria for choosing an electronic health record vendor?
A. Providing training for staff
B. A system that can only be accessed by the medical office and not by other health care entities
C. CCHIT certified
D. Has customizing options
E. Controlled cost

All are Core objectives of the Meaningful Use program EXCEPT:
A. CPOE
B. Drug-to-drug allergy interaction
C. Maintain an active medication list
D. Implement drug formulary checks
E. Implement 1 CDS rule

The initial planning process for transitioning to the EHR might include:
A. Performing research on EHR products
B. Networking with other practices about their implementation process
C. Preparing relevant information for staff meetings
D. Assigning a project leader
E. All of the above

Documentation audits should verify the following:
A. Data capture
B. Procedures performed or services rendered are consistent with the conditions diagnosed and treatment or services billed
C. Progress notes show no evidence of cloning
D. Prescribing activities are transparent and well documented
E. All of the above

The Centers for Medicare and Medicaid Services (CMS) recommend introducing the computer to the patient using the three C’s:
A. connect, collaborate, and close
B. constant, conformed, and closed
C. connect, collect, and constraint
D. connect, claim and collaborate
E. conform, care and connect

Information may be entered into the patient chart in the following way:
A. Data input from interfaced systems
B. Voice recognition technology
C. Scanning documents
D. Direct keying
E. All of the above

Which of the following is an example of a fraudulent practice in the EHR?
A. Electronically signing documents one by one
B. Having batches of documents display the same date and time
C. Reviewing other documenters’ work and signing
D. Assigning codes based on the visit documentation provided by both the MA and doctor
E. Any of the above

Structured data entry allows the doctor to customize the documentation for each patient.
A. True
B. False

Training needs will vary depending on the level of computer experience for the individual.
A. True
B. False

EHR access and operating privileges will vary from user to user.
A. True
B. False

A modified hybrid office:
A. Uses EHR for new patients only
B. Uses paper records only until the old records can be entered into the EHR
C. Uses paper records for established patients only
D. Is using practice management software, but not EHR
E. Stores the same record on both the EHR and paper record as a backup

SimChart for the Medical Office allows email exchange between the doctor’s office and patient email accounts.
A. True
B. False

Once the retention period is over, the chart may be:
A. Purged
B. Closed
C. Destroyed
D. Inactive
E. Any of the above

Purging is:
A. Reorganizing active patient charts to make more for new charts
B. Moving old records to a microfilm or storage CD
C. Destroying inactive records by erasing the hard drive
D. The practice of removing inactive and closed health records away from active records
E. All of the above

Which of the following statements is true of the waiting room?
A. Toys are OK as long as they are cleaned daily.
B. The waiting room is a common place for patients to advertise their businesses.
C. During election years, it is appropriate to keep political literature in the waiting room.
D. The waiting room should be dim due to the risk of patients having illnesses that cause sensitivity to light.

Which type of patient correspondence can be created in SimChart for the Medical Office?
A. Email
B. Phone Messages
C. Letters
D. All of the above

Giving two or more patients the same appointment slot with the same provider:
A. No show
B. Double-booking
C. Multiple slots
D. Fixed schedule
E. Wave scheduling

Which is true of referrals?
A. They can be created using the Correspondence link.
B. They are used when the physician is requesting the option of another doctor.
C. They are generated from the Forms Repository in SimChart for the Medical Office.
D. They are documented in the SimChart for the Medical Office appointment book.
E. They are generated from the Billing/Coding module only.

Which of the following is not a way to avoid duplicate charts?
A. Ask whether patients have been seen at the practice before.
B. Create a new record for patients who have not been seen in the office for more than 3 years.
C. Ask established patient if his/her name has changed.
D. Ask established patient if he/she goes by a different name.
E. Set up the patient record using the name listed on the insurance card.

SimChart for the Medical Office allows the user to view the appointment book by exam room, provider, day, week or month.
A. True
B. False

Patient records are classified by all of the following except:
A. Active
B. Inactive
C. Closed
D. Insurance type
E. All of the above

Which is not an example of backing up the EHR?
A. Charging a portable laptop
B. Keeping backup procedures at a secondary location
C. Keeping backup procedures at the main office only
D. Having the EHR vendor maintain the backup procedures
E. Backing up the EHR frequently throughout the day

Which of the following is not a guideline for e-visits?
A. E-visits may be offered to new and established patients.
B. Communication must occur over a HIPAA compliant online connection.
C. Provider must document the e-visit.
D. Provider should define the time period during which the e-visit will be completed.
E. All are guidelines.

Congestive heart disease and asthma are examples of:
A. Acute condition
B. Chronic condition
C. Metastatic condition
D. Primary illness
E. Chief complaint

The patient states the back pain has lasted 2 weeks. This is an element of “timing” to be documented in the chief complaint record.
A. True
B. False

Weight and height are considered:
A. Vital signs
B. Anthropometric measurements
C. BMI
D. Occipitofrontal circumference
E. None of the above

Patient complains of urinary frequency:
A. PMH
B. CC
C. ROS
D. HPI
E. Primary encounter

Documentation for immunization would include:
A. Name of immunization
B. Date given
C. Person administrating immunization
D. Location of injection
E. All of the above

Patient complaining of dizziness:
A. Symptoms
B. Duration
C. Chronology
D. Exacerbation
E. Associated signs and symptoms

When a note is signed electronically, the provider is representing that everything within the note is correct.
A. True
B. False

Diagnosis is Type 1 Diabetes is an example of:
A. Subjective
B. Objective
C. Assessment
D. Plan
E. Evaluation

Within a Comprehensive Exam, the user can select which appointment type?
A. Annual Exam
B. Diagnostic / Lab Results
C. Phone Consultation
D. Patient Dashboard

Genetic disease risk would be covered under which part of history?
A. Family
B. Social
C. Past medical
D. Surgical
E. Immunizations

A technology that converts speech into text as the provider speaks into a microphone:
A. Voice recognition software
B. Voice activated software
C. Speech recognition software
D. Speech translation software
E. Audio trail

URI lasting over the past 5 days:
A. Symptoms
B. Duration
C. Chronology
D. Exacerbation
E. Associated signs and symptoms

An evaluation and management service provided by a physician or other qualified health professional to an established patient using a Web-based or similar electronic-based communication network for a single patient encounter that occurs over safe, secure, online communication systems:
A. E-visit
B. Web visit
C. Online consultation
D. Both A & B
E. All of the above

The administration and results of a patient’s peak flow meter would be documented in Out of Office Order Entry.
A. True
B. False

Documentation:
A. Makes diagnosis and treatment more efficient and effective
B. Promotes patient safety
C. Serves as a risk management function
D. Provides evidence of care
E. All of the above

Once an Encounter is created, the first clinical record to land on is:
A. Forms
B. Chief complaint
C. Allergies
D. Health history
E. Appointment book

Blood Pressure is 120/80 mg/dl is an example of which kind of data?
A. Subjective
B. Objective
C. Assessment
D. Plan
E. Evaluation

Vital signs, anthropometric data, imaging studies, and laboratory tests are examples of:
A. Subjective
B. Objective
C. Assessment
D. Plan
E. Evaluation

Smoking status of the patient would be discussed under which history type?
A. Family
B. Social
C. Past medical
D. Surgical
E. Immunizations

General Health Panels, Pap Smear results, mammograms and dental visits are all documented as:
A. Health History
B. Preventive Services
C. Progress Note
D. Order Entry
E. Progress Note

The reason for the patient to seek care from the provider is called:
A. PMH
B. CC
C. ROS
D. HPI
E. Primary encounter

An allergy to “latex” would classified under:
A. Medication
B. Environmental
C. Food
D. Progress note

Data documentation in the patient’s own words about why they present to the office is:
A. Subjective
B. Objective
C. Assessment
D. Plan
E. Evaluation

The dizziness is on and off during the day:
A. Symptoms
B. Duration
C. Chronology
D. Exacerbation
E. Associated signs and symptoms

ROS means “review of symptoms.”
A. True
B. False

A tetanus injection would be coded from:
A. E&M
B. Medicine
C. Volume I
D. Category II
E. Radiology

Which of the following pieces of information is NOT found on the patient encounter form?
A. Patient name
B. Physician’s NPI number
C. Codes for services performed
D. Codes for diagnosis
E. Insurance policy number

Electronic claims are sent via fax machine.
A. True
B. False

Medicare is an example of a:
A. Tertiary payer
B. Secondary payer
C. Guarantor
D. Subscriber
E. Third-party payer

________codes are supplemental codes used to help researchers collect data, track illness and disease, and measure quality of care.
A. E&M
B. Category III
C. Volume I
D. Category II
E. Category I

_________codes are temporary codes applied to emerging technology.
A. Category I
B. Category II
C. Category III
D. Volume I
E. Volume II

_______ is a uniform language for describing procedures and treatments performed by healthcare providers.
A. CPT 4
B. CPT 5
C. ICD-9-CM
D. ICD-10-CM
E. HCPCS

_______is an unintentional deception in which a provider inappropriately bills for services that are not medically necessary, do not meet current standards of care, or are not medically sound.
A. Fraud
B. Abuse
C. Complaint
D. Compliance
E. None of the above

_______________is a legal doctrine which holds that medical services rendered must be reasonable and necessary according to generally accepted clinical standards.
A. Medical needs
B. Medical authorization
C. Code linking
D. Medical necessity
E. HIPAA

The process of assigning standard numeric or alphanumeric characters to diagnoses, procedures, and treatments is called:
A. Documentation
B. Coding
C. Reimbursement
D. Filing
E. Sorting

Medicaid is a third-party payer.
A. True
B. False

Ultrasound would be coded from:
A. E&M
B. Medicine
C. Volume I
D. Category II
E. Radiology

The ______is an electronic claim format used to gather reimbursement from insurance payers for the physician.
A. CMS 1500
B. CMS 1400
C. UB 1500
D. HIPAA 5010
E. None of the above

Patient data, such as blood sugar results from glucometers, may be downloaded into a personal health record.
A. True
B. False

Which of the following are features of Personal Health Records?
A. Synchronized with blood pressure cuffs
B. ICE notification
C. Download patient data from scales
D. Drug alerts
E. All are innovative features

The PHR is owned by the patient.
A. True
B. False

A server that provides data transfer and storage space at remote locations:
A. Host
B. Patient portal
C. Personal Health Record
D. Network
E. Server

Mobile apps like ZocDoc and HealthTap are popular health applications designed to increase patient engagement in their health.
A. True
B. False

The EHR is owned by the patient.
A. True
B. False

The PHR is a covered entity under HIPAA.
A. True
B. False

Which of the following is NOT a benefit to the Personal Health Record?
A. Take an active role in the PHR.
B. Learn about the diseases and conditions.
C. Build support from others with similar conditions.
D. Benefit from duplicate testing and reassurance.
E. Monitor medications and potential drug interactions.

A comprehensive, electronic or paper-based record of health information controlled by the patient, through which he or she can access, manage, and share confidential health information:
A. Personal Health Record
B. Individual Health Record
C. Electronic Health Record
D. Electronic Medical Record
E. All of the above

This method of keeping a Personal Health Record includes a monthly subscription and is secure. Patients have access to a database of health information:
A. Paper-based Personal Health Record
B. Personal Health Record Software
C. Online Personal Health Record
D. Any of the above

Patients who want to have their health information in electronic form but do not wish to store their private information online:
A. Paper-based Personal Health Record
B. Personal Health Record Software
C. Online Personal Health Record
D. Any of the above

This method is inexpensive, easy to maintain, and secure. The chief drawback is the difficulty of sharing information:
A. Paper-based Personal Health Record
B. Personal Health Record Software
C. Online Personal Health Record
D. Any of the above

Document that specifies which life-sustaining treatments (e.g., mechanical ventilation and tube feeding) should be administered or withheld if the person becomes incapacitated:
A. Advanced directive
B. Medical power of attorney
C. Living will
D. Authorization for the release of information
E. All of the above

Personal Health Records can monitor drug interactions and usages.
A. True
B. False.