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Test 1
| Question | Answer |
|---|---|
| A physical collection of an individual's healthcare information is termed: | patient chart, patient record, Electronic health record, & EMR |
| Which items are found in the patient record? | Immunization records, operative reports, living wills, & referral letters. not Patient driver's license |
| An individual who is responsible for putting information in the patient chart | Documenter |
| Who is not the documenter of the patient chart? | patient |
| When accompanying a patient into the exam room, the medical assistant (MA)? | Reason for visit |
| All additions to the medical recorrd must be signed by | Doctor |
| Voioe recognition software | all of the above |
| The receptionist would commonly document | Patient appointment times |
| The owner of the physical medical record: | Belongs to the one who created the document |
| Patient needs his past records for another app | Receptionist has patient to sign a records release and asks doctor what info to copy |
| Which of the following is NOT a core function of a well-designed EHR | Health information management, results management, patient support, reporting & population health. |
| The doctor asks the medical assistant to print a handout on hypertension for a patient to take home. Example of a EHR core function | Patient support |
| Doctor prescribes patient an antibodic. perscription sent to pharmacy. pharmacist notices patient is allergic to it. What core function is it? | Orders management |
| releasing history with patient permission is what core function | Electronic information & connectivity |
| What core function is statement being printed from the EHR directly after the patient visit? | Health information & data management |
| Which core function is monitoring the swine flu? | Reporting & population health |
| What allows practitioners to tailor the care of an individual patient by making sure it adheres to published, evidence-based guidelines for the patient's specific diagnoses. | CDS |
| The amount of money a patient is contracted to pay out of pocket at each visit is called: | Co-payment |
| Practice management software does | Documents results of lab tests |
| A standard form that speeds claims processing for doctors & suppliers | CMS-1500 claim form |
| What is NOT a factor in adopting the EHR | Physician schedule |
| The medical record can contain legal documents but is NOT itself a legal document | False |
| Maintaining patient records is optional for healthcare providers. | False |
| The contents of the patient health record are standardized from office to office | False |
| Lab results would be an example of IIHI | True |
| The patient is the owner of the physical health record | False |
| A medical office may charge for copying medical records | True |
| It may be possible for an individual to penetrate EHRs security despite precautions | True |
| The implementation of an EHR increases patient satisfaction with the medical office. | True |
| Communication among various treating healthcare providers, pharmacies, & allied healthcare workers will be limited until the EHR interoperability has been achieved | True |
| Workflow redesigns can not be addressed until the EHR system goes live. | False |
| Backing up data in the patient's EHR is mandated by HIPAA | True |
| Overdocumentation can leave a provider vulnerable to charges of fraud & abuse | True |
| Dawn was asked to sign a ________ when receiving her flu shot. | Consent |
| Offices submitting claims electronically are | Covered entities |
| A patient insurance form is | IIHI & PHI |
| Progress notes sent to specialist's office | The minimum necessary standard |
| Passwords and screen savers are examples of____________ | Safeguards |
| ___________ are a set of rules & standards of conduct that grow from our understanding of right or wrong. | Ethics |
| doctor wants a follow up app. to discuss patient's test results | Confidentiality |
| HIPAA addressed the following | Privacy, Security, Portability of insurance coverage & physical safeguards |
| Protected health information (PHI) | Health information stored & transmitted electronically, Health information stored on paper or electronically, Conversions that hold personal information & Releasing paper-based patient records -- all of the above |
| The Privacy Rule requires providers to do all of the following | Post a privacy notice, Offer authorization form for release of PHI, Train staff members of the policies of HIPAA not Designate a privacy officer |
| What is not a covered entity? | Workers' compensation programs |
| The Privacy Rule does not prohibits the discussion of patient information | Over the telephone |
| The initial planning process for transitioning to the EHR includes | Performing research on EHR products, Networking, Preparing relevant info for staff meetings, Assigning a project leader |
| An office that uses EHR for new patients & paper-based records for extablished patients is called | Hybrid office |
| What is not a criterion for choosing an EHR? | System can only be accessed by the medicl office |
| In point-of-care (POC) documentation | done by the provider during encounter, documentation most convenient to the doctor, patient, medical assistant & doctor write the documentation, documentation is first written on paper & then scanned into the EHR |
| Information me be entered into the patient chart through | Data input, Voice recognition, Scanning, & direct keying |
Created by:
shagkitty