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chapter 7 EHR

Term	Definition
Which of the following features is used to define criteria to search patient charts for health needs and screenings?	Chart Evaluation
The chart evaluation feature helps support which of the following?	All of these
Which of the following does a user select to setup chart evaluations?	The administration menu
What does the abbreviation NGC represent?	National Guideline Clearinghouse
Where in spring charts can the user set up the super bill?	In the administration panel on spring charts server
Which of the following is a preventative check-up to test for or inoculate against significant diseases?	Wellness Screenings
In the chart evaluation setup window which of the following may be accessed via the internet to evaluate medical standards for wellness screenings?	NGC
In the edit chart evaluation item window users can define criteria specifications by which of the following?	All of these
Which of the following information can be specified under the actions criterion?	Test, procedure, or encounter
Which of the following criterion is optional when setting up a chart evaluation item?	Diagnosis
If a patient is current with the evaluations and health management screenings which of the following messages will the user receive?	Pt up to date with recommendations
What message will a user receive to indicate that no chart evaluations have been set up on spring charts server?	No criterion set
Which of the following is an HER-integrated system designed to assist physicians and other healthcare professionals with evidence-based decision making concerning patient healthcare using clinical databases?	Clinical decision support
What time of the day is recommended that a user scan the entire patient database and apply the chart evaluation criterion to all patient charts?	After hours
Which feature helps the physician to determine the correct evaluation and management code for office visit encounters?	E&M Coder
What steps should a user take to set up the E&M Coder feature in a network environment?	Select E&M Coder from the administration menu of spring charts server
In the E&M Coder setup window users may define keywords for which of the following?	All of these
Which of the following terms typically contains the medical office’s most common procedure and diagnosis codes and descriptions for the purposes of recording the physician’s selection and billing?	Super bill
In spring charts which of the following is designed to display codes and items which are often overlooked or not available in the OV exam and can be billed?	Super bill
The super bill may display procedures and codes not included on the OV documentation, including which of the following?	All of these
In which of the following locations of the office visit note will the clinician record the patient’s symptoms and complaints?	(CC)tab
In which of the following locations of the office visit will the clinician record the patient’s blood pressure and weight?	(Vitals) tab
In which screen can the patient instructions be accessed?	The office visit screen
When creating a patient instruction sheet a user must save the document in which format?	RTF
How does a user access the new pt handout window to import a RTF file or create his/her own patient instructions document?	In the new menu select new pt instructions
What option(S) does spring charts offer to create a patient instruction sheet?	Create or import a patient instruction document
Which organization’s website does the textbook recommend as a reputable source for routine patient instructions?	Both the Food and Drug Administration and National Institutes of Health Medicine Plus websites
Which of the following options will open a browse window to import a patient instruction sheet as a RTF document?	(Import Pt Instructions)
To administer a patient instruction sheet, which of the following will the user open?	A new or existing OV note
Once the provider has created a patient instruction sheet, what iption does the provider have to get the document to the patient?	The patient may receive a printed copy or instructions via e-mail
Which of the following are specific documents that guide all individuals involved with a patient’s care, outlining the appropriate treatment to insure the optimal outcome?	Care plans
What is another name for care plans?	Practice guidelines
Which of the following is a clinical decision support tool available in ONC certified HER programs?	All of these
Under which menu of the OV screen is the care plan feature accessed?	Tool
Once the care plan feature is selected, what option(s) is the user given to create a care plandocument?	Import a care plan from either a stored document or the NGC website
Which of the following websites holds numerous medical treatment plans containing objective, detailed clinical information for physicians, nurses, and other healthcare professionals?	NGC website
Where may a user view a care plan associated with a patients office visit?	The care plan may be viewed at the bottom of the OV note
Which of the following is automatically added to the test order before it is printed?	Diagnosis from office visit
A physician’s order is created by clicking which of the following icons located on the lower middle of the test panel?	Printer Icon
Using spring charts HER, how does the provider order tests that must be performed at an outside testing facility?	COPE
The E&M coder determines an appropriate E&M code based on which of the following?	All of these
In which of the following locations can the user access the patient instructions manager from the main window?	Edit
Which of the following enables the provider to indicate the procedure that was conducted by drawing on inbuilt templates?	Draw feature
Which of the following describes how to access the draw option?	With the OV window open, the provider will access the tools menu and select the draw option
With the simple draw window open, in which menu may the user find a desired body section?	Template
Where is the draw item stored?	With the OV note
Which of the following is stamped on the follow-up segment on the note if a draw item is stored?	Graphic
Which of the following activities in the edit menu within the draw program may theuser choose?	All of these
Which menu may be selected in the simple draw window to import more elaborate illustrations such as a jpg image?	Background image menu
Which of the following may be added with the (T) button to clarify content of an image?	Text
How many draw items may be added to each office visit note?	One
Which of the following is a comprehensive database of evidence-based clinical practice guidelines and related documents/	NGC
Which of the following information can be specified under the recurring criterion?	Recurrence of event
Which of the following information can be specified under the gender criterion?	Sex of the patient
Which of the following is true regarding the linking of the wellness screenings to a diagnosis, lab, or medicatin from the patient’s charta?	Linking is optional
Line items marked with which color asterisk in the edit chart evaluation item window are mandatory when setting up chart evaluation criteria?	Red
When should a user scan a patient’s chart and apply the chart evaluation criteria?	During a patient encounter
When the user selects (done), at the bottom of the evaluate chart menu, where are the patient’s response and a summary of the evaluation items recorded?	Care tree under encounters
Wellness screenings are critical elements in preventative healthcare for which members of the population?	Both older and younger patients
The ONC requires all certified HER programs to send appropriate healthcare reminders to patients in which age groups?	Both age groups of 5 and under as well as 65 and older
When the healthcare reminder form letter is completed the userclicks which of the following buttons to print the letter?	Done
Once a clinician orders attest in the OV screen, then records the in-house test results in the pending tests area of the program, the results can be viewed in which of the following locations?	OV note
Who has complete discretion in deciding whether any given educational resources is appropriate for the patient?	Physician
Within spring charts the mouse’s right click button may not support which of the following functions?	All of these
Who should approve all patient education material downloaded from the internet before a user adds it to the HER database?	Physician
Which of the following keyboard keys can be used for copying material in the event the mouse’s right click function doesn’t operate in spring charts?	(ctrl)+(c)
Which of the following keyboard keys can be used for cutting material in the event the mouse’s right click function doesn’t operate in spring charts?	(ctrl)+(x)
Which of the following keyboard keys can be used for pasting material in the event the mouse’s right click function doesn’t operate in spring charts?	(ctrl)+(V)
Which of the following must the user do before saving a new patient instruction sheet?	Assign a title
Which of the following buttons in the eit patient instruction window should the user select to map a patient instruction document to a health care item?	(map PI)
Which of the following allows users to attach documents to patient charts?	Import file cabinet document
The file cabinet document feature allows the user to add documents with which of the following file extensions?	All of these
When an imported document is opened within the patient’s chart, which of the following programs opens it?	All documents are opened in the original program
Which of the following options enables communication between image-capturing devices (including scanners, cameras, web-cams) and computer programs?	Acquire
With clinical decision support, which of the following are integrated with healthcare knowledge databases enabling the provider to make quality treatment choices for the patient?	Both observations and assessments made by the provider
In the chart evaluation items window, which button will the user select to open the edit chart item window to create a new chart evaluation item?	(new)
Chart evaluation criteria change from clinic to clinic based on which of the following?	Clinic specialty
The (communication Pref) radio button is used by the HER program to determine which of the following communication preferences of the patient?	Regular mail or e-mail
What color is the panel in the routing slip window where super bill items are displayed?	Gray
Which of the following is NOT a mapping option available for selection in the map patient instruction window?	Immunizations
Which of the following windows instructs users that one or more resource documents are available that addresses a specific patient issue?	Information available
When patient instruction sheets are printed for a patient, where in the SOAP note is it documented that the resource was given to the patient?	Plan
Which of the following provide additional information in the physician’s notes?	Both photographs and sketches
When any window is accessed within the patient’s chart, what does the HER program place in the header of that window?	Patient’s initials
Which of the following indicates the font style of the text font used in the draw program?	Plain
Which of the following indicates the size of the default text font used in the drawing program?	10-point
Which of the following information is automatically added to imported documents when the file cabinet document winow is accessed from the patient’s chart?	Patient name
The file name of a document stored on the network appears in which color font in the import window?	Blue
TWAIN technology has been incorporated into equipment manufactured since which year?	2000
In which of the following environments does the TWAIN technology operate?	Both windows and macintosh
Which of the following enables one touch scanning, allowing the user to operate a scanner directly from spring charts?	A graphic user interface
Once opened in a patient’s chart, which of the following can be done to an imported document?	Both edited and resaved
In which of the following areas of spring charts are all ordered tests sent to?	Pending tests
In which of the following windows can the user create and select care plans?	Care plan
Using the E&M coder, the number of body areas examined determines which of the following?	Level of E&M code recommended
Which of the following topics could be included in a patient education resource contained within the EHR program?	All of these
The ONC requires all certified EHR programs to be able to identify educational resources that are patient-specific based on which of the following?	All of these
In Microsoft windows environments, documents created in word pad are automatically saved in which of the following file formats?	.rtf
Which of the following describes what happens to a plan of care document after it is attached to the office visit screen?	It becomes a permanent part of the Office visit note
Which of the following will the user select to open a file cabinet document attached to the patient’s chart?	(Doc)

Created by: cborne

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