click below
click below
Normal Size Small Size show me how
Health Records
Chapters 1-6 review
Question | Answer |
---|---|
In 2004 President George W. Bush commented: | "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care." |
Which of the following is a feature of the EHR? | Personal Health Record |
What is the difference between an electronic medical record and a computerized patient record? | There is no difference. |
When might internet technologies benefit a health-care provider? | When accessing their EHR from a home office. When accessing their EHR from a nursing home. When accessing their EHR from a hospital. |
What is one benefit of an EHR over paper charts? | EHR is centralized. |
Who will provide incentive payments to doctors for using a certified EHR product and demonstrating meaningful use? | CMS |
Which of the following describes a method in which EHRs enhance communication between providers and their staff? | Instant messaging |
Software content created in a language common and accessible by all EHR is referred to as: | Neutral |
What is the name of a set of standards, services, and policies that enable secure health information exchange over the Internet? | National Health Information Network |
Which of the following does not represent a manner in which the Regional Extension Centers were mandated to assist with implementation of EHR? | Subsidize the expense of new hardware and software. |
Which of the following terms can be defined as the time and place the healthcare provider gives the patient medical care? | Point of care |
Which of the following allows the patient access via the Internet to store and update personal medical information and ask questions about prescriptions, appointments, or other medical concerns? | PHR |
Which of the following indicates the primary difference between EMR and EHR programs? | EHR presents a full range of higher-end functionalities not available with EMR. |
Why do HIPAA regulations affect EHRs? | Because of the portability of the patient's protected health information. |
In what way(s) must EHRs programs provide password management? | Ability to safeguard Ability to change Ability to create |
What is meant by access authorization? | Specific assignable security levels regulate who may access, modify, delete, or transmit specific information. |
How is prevention of intentional or unintentional disclosures and modifications to PHI accomplished? | By tracking user access. |
What is one reason the federal government uses CHI standards? | To promote interoperability between EHR systems. |
What is the purpose(s) of the NCPDP? | To create and promote standards for the transfer of data to and from retail pharmacy services. |
What is the purpose of the IEEE? | It's an international organization for the advancement of technology related to electricity. |
To what do the 11073 standards refer? | The Medical Device Communication Standards |
What do the Medical Device Communication Standards established by IEEE 11073 address? | The interoperability of medical devices. |
Which of the following advocates for uniform healthcare data sets for underrepresented populations? | NCVHS |
SNOMED CT is an acronym for which of the following? | Systematized Nomenclature of Medicine Clinical Terms |
What does SNOMED CT provide? | Standard terminology for laboratory result contents, anatomy, diagnosis, medical problems, and nursing. |
What are HIPAA's Transaction and Code Sets? | Standards for electronic exchange of information for billing and administration. |
Which of the following can lead to errors and potential injuries to patients? | Manual order entry Nonstandard abbreviations Illegible handwriting |
Which of the following is a benefit of CPOE functions in an EHR? | Expedient order completion Reduction in errors related to handwriting Opportunity to check for duplicate or incorrect tests |
To which of the following are EHR vendors required to submit their EHR products for testing and certification? | ONC-ATCB |
Which of the following authorized the ONC to promote EHR adoption by means of a financial incentive program based on healthcare practitioners' meaningful use of the technology? | HITECH |
Because of the possible privacy threat to PHI, practitioners opt to communicate electronically with patients with which of the following methods? | Patient Portal |
Which of the following are issues the healthcare industry grapples with in creating necessary technology to guarantee total security of ePHI? | Both E-mail Security and Digital Signatures |
When does HIPAA require the use of electronic signatures? | Never |
Which of the following indicates the use of the Address Book feature? | To store, edit, and search for addresses of supporting businesses and personnel. |
Which of the following describes the use of the New Patient feature? | To create an electronic chart for a new patient. |
Which of the following explains why the Patient ID field is shaded gray? | The program will assign a Patient ID number after the information is saved. |
What role does the [tab] key play within SpringCharts? | Pressing the [tab] key moves from field to field |
In which of the following fields of the New Patient window can a patient be designated as nursing home patient, obstetrics, gynecology, disabled, and so on? | Category |
Which of the following will occur if a social security number entered matches another patient's record? | A duplicate patient alert is triggered. |
Which of the following describes why race and ethnicity lists are coded in the SpringCharts database? | To allow physicians to adjust their bedside manner to the customs of the patient For advertising statistics for the practice For reporting to state and federal healthcare surveillance agencies |
Which of the following best depicts the difference between race and ethnicity? | Race is associated with biology and ethnicity is associated with culture |
Which of the following is a benefit of not needing to add punctuation (i.e. parentheses, dashes, etc.) to phone numbers and social security numbers in SpringCharts? | Speed of data entry |
Which of the following is typically used in large group practices to add other providers from within the same clinic to a patient's information screen? | Other provider details |
Which of the following functions enables recovery of a previously removed patient? | Undelete |
Which of the following is NOT a requirement for demonstration of meaningful use as defined in Stage I for Core Measures of Patient Demographics? | Drug allergy |
What does the Appointment Schedule display? | Past, current, and future appointments for patients. |
Which window must be open in order for a user to set up appointments and breaks? | Edit Appointment window. |
Which of the following describes a New/Unregistered patient? | A patient whose information has not been entered into SpringCharts database. |
Which of the following describes an Existing/Registered patient? | A patient whose information has been setup in SpringCharts database. |
Which of the following describes why a new/unregistered patient cannot be documented as a no show in SpringCharts? | An electronic chart has not been created for them in the database. |
Which of the following is a function that SpringCharts allows in regard to scheduled appointments? | SpringCharts gives the ability for a clinic to chart a no show for patients who do not show up for their appointments. |
Which of the following displays a lineup of icons that gives users shortcut access to the program's most commonly used functions? | Toolbar |
Which of the following indicates appointment intervals on the SpringCharts schedule? | 10 minutes |
Which of the following are established and modified in the administration panel of SpringCharts? | Starting time slots Ending time slots Appointment-length intervals |
From the Appointment Schedule , which of the following is a method to navigate to future or prior months? | Clicking on left or right arrows on the month title bar |
Which of the following represents the time slot options available in the Appointment Setup window? | From 10-60 minutes |
Which of the following users may access the same patient chart simultaneously? | All users. |
What does the Category Preferences table on the SpringCharts server enable the clinic administrator to create? | Customized predetermined lists of healthcare data. |
Which of the following refers to patient information subject to change with each office visit? | Dynamic |
From which menu can a user access the option to print a patient's history of diagnosis, prescriptions, or procedures? | From the File menu in the patient's chart. |
Which of the following is a reason to record past and ongoing immunizations in the EHR? | Allows the physician and staff to see a complete immunization history |
Which of the following information can be viewed as an illustrated graph as a result of graphing vital signs? | Blood pressure. Height/weight data. Body mass index. |
Which of the following is a simple, safe, and effective way to protect children and adults from a wide variety of potentially deadly diseases? | Immunization |
Which of the following allows changes made in the PMS system to be reflected in the EHR in real time? | Interfacing. |
Which of the following mandate that a patient's routine medications and problem list be transmitted to the SureScripts clearinghouse each time an electronic prescription is sent? | ONC |
In the Edit Patient Insurance window, which of the following enables the user to record additional information, such as the patient's deductible? | Details |
Which of the following best describes a History & Physical (H&P) Report? | It is the documentation of a patient's face sheet and medical history combined with the physical exam. |
Once an office visit is locked with the Permanent Sign & Lock feature, who may unlock or edit the office visit? | It cannot be unlocked or edited by anyone. |
Which of the following describes ordered tests that have not yet been processed? | Pending |
Which of the following indicates the location of the H&P report once the user selects [Done]? | Care Tree. |
Which menu in the OV screen provides quick access to the Face Sheet chart categories? | Edit menu |
In which menu of the OV screen can a user access, view, or print a patient's immunization? | Edit menu |
Which menu in the OV screen provides access to features such as Lab, Diagnosis List, Immunization, Medications List, Procedures List, and Graph Vital Signs? | Actions menu |
When will the option to add an addendum to an OV note be available? | When the OV note was permanently signed and locked. |
Examination Reports detail the office visit note and are designed for which of the following? | Patient |
Which of the following would NOT be documented under the Plan in a SOAP note? | Pregnancy |
Which of the following indicates why the BMI (body mass index) field is gray? | The program calculates this data from the patient's measurements of height and weight |
Which of the following is the purpose of the lock symbol next to office visit notes in the patient care tree? | Indicates the note is permanently signed and locked |