EMR 101 Chapters 1-3 Exam Questions and Answers (Already GRADED A)

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Though the costs of implementation will be high, which record-keeping costs will ultimately drop as a result of implementing an electronic health record? -Copying Costs -Cost of folders and clips ... to file each record -Transcription costs -Training Costs Cost of folders and clips to file each record Of the following, which is an advantage of adopting an electronic health record? -the cost of implementing an electronic system -the requirement of little time or effort by the office staff -the potential for interoperability with other computerized systems within the practice or hospital -the high learning curve the potential for interoperability with other computerized systems within the practice or hospital You are a healthcare professional at Greensburg Medical Center and you have just shown a patient, Mrs. Clark, to the check-out desk, where the billing coordinator had just taken the encounter form (superbill) for the visit. Dr. Daniels came to the window and stated that Mrs. Clark left the exam room before receiving her flu shot. What will occur in this case? -Mrs. Clark has already given the encounter form to the billing coordinator, so she will need to make another appointment. -Mrs. Clark will be taken back to the exam room; she will be given the shot by the healthcare professional, who will document it in Mrs. Clark's record and will then update the encounter form to reflect the charges for the flu shot; at that point, Mrs. Clark will return to the check-out desk. -Mrs. Clark will be taken back to the exam room and will be given a flu shot; however, she will not be charged since she has actually already checked out. -Mrs. Clark will be taken back to the exam room and will be given the shot by the healthcare professional; she will then be free to leave. Mrs. Clark will be taken back to the exam room; she will be given the shot by the healthcare professional, who will document it in Mrs. Clark's record and will then update the encounter form to reflect the charges for the flu shot; at that point, Mrs. Clark will return to the check-out desk. Roberta is a healthcare professional at Dr. Ingram's office. She has a patient on the phone who wants to make an appointment with Dr. Ingram. What will Roberta first take into consideration when looking for an open appointment time? -the reason for the patient's visit -the patient's age -Dr. Ingram's vacation schedule -the patient's schedule the reason for the patient's visit The patient's bill for an encounter is ready to be sent to the insurer at what point in the encounter? -after the insurance company has pre-approved the visit to the care provider -after the patient has been seen by the care provider -after the patient has scheduled the appointment -after the care provider has documented a diagnosis or diagnoses and all charges have been posted after the care provider has documented a diagnosis or diagnoses and all charges have been posted You are a registrar in the admitting office of a hospital; a patient presents to register for an outpatient laboratory test. What will you first access to determine if that patient has ever been seen at that hospital before, or whether you must register him for the first time? -Master Patient (Person) Index -Diagnosis Index -Master List -Account Summary Master Patient (Person) Index Which of the following statements accurately describes duplicate patient registration entries in an electronic health record system? -There is no need for the registration process within the electronic health record system. -It is impossible to duplicate a patient registration in an electronic system. -Duplicate patient registrations can occur if the patient's name was misspelled or the patient was previously registered under a different name. -Duplicate registrations are not a problem in an electronic health record. Duplicate patient registrations can occur if the patient's name was misspelled or the patient was previously registered under a different name. Sean Brown is a new care provider and has never before used Prime Suite. He is frustrated, and though you have been trying to help him, he is still having difficulty. What would be sound advice to give to Dr. Brown? -Direct him to the User's Guide in Prime Suite and show him the index, contents, and search features. -Make arrangements to meet him at the office on a Saturday to teach him how to use the system. -Have him call the Prime Suite 24-hour help line to speak with a technician. -Have him ask one of the other care providers in the practice for assistance. Direct him to the User's Guide in Prime Suite and show him the index, contents, and search features. In a physician's practice, the documentation of a patient's office visit is often referred to as a -physical exam. -progress note. -discharge summary. -history of present illness. progress note. During the history of present illness, the healthcare professional asks Ron Albertson for his preferred pharmacy. The healthcare professional then enters the information into Prime Suite. After the care provider has examined and diagnosed Mr. Albertson, he prescribes Amoxicillin and electronically sends the prescription to Mr. Albertson's chosen pharmacy without having to enter any additional information into the ePrescribe module. This is an example of -profitability. -interfacing. -seamlessness. -interoperability. interoperability. Under which category would the patient's marital status be listed? -Confidential -Family Medical History -Social History -Flow Sheets Social History Memorial Hospital is in the process of researching a new facility-wide electronic health record system. The ___________________ would be responsible for assessing the budgeting process, funding, and monitoring the monetary aspects of the project. -chief executive officer -chief financial officer -billing manager -health information manager chief financial officer Which of the following is not a professional organization related to the fields of health information, medical assisting, or allied health? -American Hospital Association -American Association of Medical Assistants -American Health Information Management Association -American Medical Technologists Association American Hospital Association A unique identifier that is required on claim forms and identifies the care provider or group practice submitting the claim is the -care provider's license number to practice medicine. -care provider's policy number. -National Provider Identifier number. -care provider's social security number. National Provider Identifier number. Which entity was founded in 2004 to certify electronic health records? -Certification Commission for Health Information Technology -National Health Information Network -Regional Extension Centers -Office of the National Coordinator Certification Commission for Health Information Technology (CCHIT) The patient has a heart rate of 68 and a blood pressure of 110/65. These are known as: -vital signs -problem list -social history -past medical history vital signs Robert Fitzsimmons is an administrator with the local hospital. His responsibilities include the maintenance and security of all of the automated systems that affect individual departments as well as the electronic health record. Mr. Fitzsimmons is a -human resources administrator. -chief nursing administrator. -health information administrator. -health systems administrator. health systems administrator. Which of the following requires completion of a competency exam, but does not result in certification? -Registered Medical Assistant -Registered Health Information Technician -Registered Health Information Administrator -Practice Workflow & Information Management Redesign Specialist Practice Workflow & Information Management Redesign Specialist When collecting data on a computer or retrieving data from a computer, the screen becomes the replacement for ______________. -face-to-face communication -the keyboard -paper -physician dictation paper Philip is a medical assistant who has been working for a medical practice with two physicians and one physician's assistant for three years. He recently applied for a supervisory position within the office, but was overlooked for the position. He is anxious to take his knowledge and experience to the next level, but never took a certifying exam, and to this point has not taken advantage of continuing education opportunities. What is the best strategy for Philip to strengthen his chances of promotion in the future? -Join the American Health Information Management Association. -Begin studying for one of the medical assisting certifying exam and schedule a date to take it. -Look for other opportunities in other physicians' practices. -Speak with the office manager and let his career plans be known. Begin studying for one of the medical assisting certifying exam and schedule a date to take it. The ____________ allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information. -Health Insurance Portability and Accountability Act (HIPAA) -Electronic Health Record (EHR) -Health Information Exchange -Institute of Medicine Electronic Health Record (EHR) "A set of standards, services, and policies that enable the secure exchange of health information over the Internet" is known as -Health Insurance Portability and Accountability Act. -Health Information Technology for Economic and Clinical Health Act. -Office of the National Coordinator. -National Health Information Network. National Health Information Network. In a hospital setting, when the patient presents for care he/she is -checked out -registered -scheduled -discharged registered A ______________________ professional would most likely hold one of the following positions: cancer registrar, privacy officer, software analyst, or compliance officer. -Certified Coding Associate (CCA) -Certified Medical Assistant (CMA) -Certified Health Care Facility Manager (CHFM) -Registered Health Information Administrator (RHIA) Registered Health Information Administrator (RHIA) Roberta has an associate degree and holds RMA certification. She mainly performs administrative duties such as appointment scheduling, registering patients, and maintenance of health records in a large physician's practice. She occasionally performs clinical duties as well, as needed. Roberta is a/an: medical assistant In a hospital setting, the management and much of the staff of the department responsible for entering, maintaining, and retrieving data from health records, are often certified through and men members of which professional organization American Health Information Management Association (AHIMA) The health information manager and the _______________ work closely to ensure a fully operational, secure electronic health record that meets the needs of all users within the facility? Information Technology Manager/Officer The staff of the ____________ will need to enter, maintain, and retrieve data from electronic health records within a hospital setting. health information department Until recent years, Registered Health Information Technicians, Registered Health Information Administrators, and Certified Health Data Analysts typically worked in which type of facility? hospitals In a physician's practice, _____________ may be the title of the person who is responsible for the overall administrative management of the practice. Office Administrator An x-ray of the ankle was performed on Daniel Way on December 16. Dr. Eberly interpreted the x-ray and dictated his impression, which then became part of the hospital's electronic health record. This impression is ____________ data. unstructured Dr. Henderson wrote a progress note in the emergency room note of Lisa Ford. This is an example of _________ data. unstructured The progress note of Amy Shaw states that she is a 51-year-old female who has a history of lower back pain following a fall off a ladder in 2007. She has been taking ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs to miss work. Based on her history and the results of the physician's physical exam, his treatment plan is naproxen sodium daily and an order for physical therapy to include TENS treatments with follow-up visit scheduled in four weeks. This is an example of a patient's health ________________. information the data of birth on a patient's record is ______________ data. structured A zip code would be an example of _______________ data. structured A record that contains a person's health history, allergies, current complaints, past medical and surgical history, and a listing of current medications, but is not considered a legal health record is a/an: personal health record Typically, paper health records are maintained how? filed in folders in numeric or alphabetic order Entering data into a computer system is also known as ____________ data. capturing The capturing of data about a patient begins at what point? When the patient calls for an appointment or arrives at the hospital for care. Which is not a core function of the EHR as defined by the Institute of Medicine? filing of insurance claims Information that identifies the patient in any way is known as _____________. Protected health information The _________ is published by he federal government and includes all actions taken by any government entity on a given date. Federal Register The Health information Technology for Economic and Clinical health (HITECH) Act is part of the ______________. American Recovery and Reinvestment Act In order to send and accept diagnosis codes using ICD-10-CM, which version of the HIPAA Code Set rule was effective as of January 1, 2012? Version 5010 We have an expert-written solution to this problem! Ina physician's office, the equivalent of a hospital's mater patient index is a/an: patient list The hospital equivalent to practice management software used in the physician's practice is known as: Registration, Admission, Discharge, Transfer System John Smith was admitted to Memorial Hospital on June 6 and died while in the hospital, on June 10. The action taken on June 10 was a/an: discharge In order for ACOs to prove that they have provided quality care while controlling costs, what is/are necessary? -one health record for each patient regardless of which provider or facility within the ACO is utilized -data -ancillary services (lab, radiology, rehab, etc.) available 24/7 -additional staff data Susan is collecting data from a patient, and she asks him for his address. The patient asks whether she means his P.O. box number or his physical street address. Susan would find the meaning of the field permanent address in the practice's ______________________. data dictionary The setting where services took place is known as the place of service code You are about to enter the marital status of a patient, and upon clicking in that field, the following appears: _Single _Married _Separated _Divorced _Widow/widowed These possible values are derived from a _____________ within the system. -library -dictionary -value list -master list library Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness; May 13, 2013, inpatient for pneumonia; and June 4, 2013, emergency department for a sprained arm. How many times will Daniel Allen's name and demographic information be entered in the MPI of Greenway Hospital? one In a hospital, what piece of data is included in the Master Patient (Person) Index (MPI) that allows a hospital to locate the corresponding health (medical) record for each patient? medical (health) record number The name, address, NPI number, and telephone number of a physician is known as ____________ information. provider In order to file a claim to Medicare, a physician's office submits a ________________ form. CMS-1500 Demographic data is a subset of __________ data. administrative Clinical Documentation Architecture (CDA) and Quality Reporting Documentation Architecture (QRDA) are both specific data standards of the broader _____________ standards. Health Level Seven (HL7) A major goal of use of an electronic health record is the sharing of important clinical information about a patient. The use of ______________ is directly related to this goal. Continuity of Care Documents (CCD) The subscriber and patient information section of a claim form includes all of the following except: assignment of benefits authorization There are certain pieces of data that must be collected in order to meet Meaningful Use requirements. Which of the following data does that? race Malone's health (medical) record number at Memorial Medical Center is 482638. This is an example of a/an _______________. unique identifier Greenway Medical center has partnered with five area physician's offices as well as a rehabilitation facility nearby for the purpose of offering high quality, coordinated care to patients in that geographic area. This partnership is known as a Accountable Care Organization. Where does the data originate that is used to prove Accountable Care Organization (ACO) success? the patients' health records. The master patient (person) index is: An index of all patients ever treated in a hospital Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness, May 13, 2013, inpatient for pneumonia, and once on June 4, 2013 in the emergency department for a sprained arm. How many encounters for Daniel Allen will be found in the MPI of Greenway Hospital? five The MPI and patient list should be kept: Permanently At Heller Memorial Hospital, all patients regardless of the type of patient emergency department, inpatient, outpatient diagnosics, etc., are registered through the dame department. This is known as: Centralized Registration The amount of time allotted for a patient's office appointment is largely dependent on the _________. reason for the visit Virginia Reed called Greensburg Medical Center to make an appointment for her annual physical exam. This step in the process is called: scheduling Amy Shaw arrives for her appointment at Dr. Rodriguez's office. She has moved since her last visit and her last name has changed due to her marriage. The healthcare professional will _______ the patient's demographic information. edit When certain fields are clicked, the most common response to that field may appear. This is known as a ________ value. Default The step that occurs after a patient is seen by the care provider is patient stops at the cashier or check-out desk. Each time a patient presents for care, the _________ should be viewed or copied to ensure accurate information is on file for billing purposes. insurance card [Show More]

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