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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