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Health Records

Chapters 1-6 review

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
Created by: 199307392