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AMB100 > Lessons 3 - 5 > Flashcards

Lessons 3 - 5 Flashcards

1
Q 
Which SmartTool(s) can you summon using the dot? (Choose all that apply.)
A) SmartList
B) SmartText
C) SmartLink
D) SmartPhrase
A

C) SmartLink

D) SmartPhrase

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2
Q

True or False: To open a SmartList, press F3.

A

False

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3
Q

True or False: SmartPhrases can contain SmartLists.

A

True

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4
Q

True or False: A SmartLink for allergies will automatically refresh if the patient’s allergies are edited during that encounter.

A

False

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5
Q 
For which of the following can you use NoteWriter? (Choose all that apply.)
A) History of Present Illness
B) Follow-up
C) Patient Instructions
D) LOS code
E) Review of Systems
F) Physical Exam
G) Certain procedures
A

A) History of Present Illness
E) Review of Systems
F) Physical Exam
G) Certain procedures

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6
Q 
How can you mark " + chest tenderness -" positive? (Choose all that apply.)
A) Click the plus.
B) Press Tab.
C) Left-click anywhere on the button.
D) Right-click anywhere on the button.
A

A) Click the plus.

C) Left-click anywhere on the button.

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7
Q 
Dr. Kristen sees the following buttons in the Notes activity. To add or edit the Note speed buttons, she should click: (Select one.)
A) Create Note
B) Arrow next to Create Note
C) Wrench
D) Bookmark
A

C) Wrench

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8
Q

True or False: After selecting a NoteWriter template, to go to HPI in NoteWriter, click on the HPI SmartBlock in the note.

A

False

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9
Q

True or False: On a NoteWriter +/- button, after you click plus, you can change it to a minus.

A

True

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10
Q

True or False: To edit the text that appears in SmartBlocks in a note, you must make the edits in NoteWriter.

A

True

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11
Q

SmartText

A

A text template that can include text, SmartPhrases, SmartLists, and SmartLinks. Frequently used in progress notes, but can be used in many different types of records.

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12
Q

SmartPhrase

A

A SmartTool that allows you to type a few characters that automatically expand into a longer phrase or block of text. For example, .pt becomes patient.

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13
Q

SmartLink

A

A SmartTool that pulls (or “links”) information from the patient record directly into your documentation. For example, if you enter .name, the patient’s name is pulled in.

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14
Q

SmartList

A

A SmartTool that allows you to choose from a list of pre-configured choices in a SmartText or SmartPhrase. These can be single- or multiple-response lists.

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15
Q

NoteWriter - Note Template

A

A type of SmartText that can include SmartBlock-type Links, which relate to the NoteWriter activity

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16
Q

NoteWriter - SmartBlock

A

A type of SmartLink used in a note template for the NoteWriter. The SmartBlock includes the Classic SmartForm or SmartForm to display as well as the text generation template to use.

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17
Q

NoteWriter

A

Tool for writing notes and uses SmartForms. An activity that generates note text based on point-and-click documentation. Information that a clinician document from the NoteWriter includes a patient’s history of present illness, review of systems, medical decision making, and physical exam.

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18
Q

Differentiate the purposes of SmartPhrases, Texts, Lists, and Links

A

..

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19
Q

The relationship between SmartBlocks and NoteWriter forms

A

..

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20
Q

The effects of using procedure documentation in NoteWriter

A

..

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21
Q

__________ might encompass an entire letter or a progress note about a visit from beginning to end, whereas may __________ are not so complex

A

SmartTexts, Phrases

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22
Q

__________ are standard blocks of text used to redue documentation time. They can be used for notes, patient instructions, letters, instruction fields in the Order Composer, and more.

A

SmartTexts

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23
Q

Both __________ and __________ often contain Lists so you can customize the information and _________ that automatically personalize the documentation.

A

SmartTexts, Phrases, Links

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24
Q

A Smart_____________ is available in all SmartTool-enabled text boxes.
A Smart_________ can be ________________ to certain types of SmartTool-enabled text boxes, and can be further restricted by factors such as patient _______ and _______.

A

Text, Phase, restricted, age, sex …?

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25
Q

Smart____________ and SmartPhrases often contain
Smart____________ (that automatically customize the
documentation) and Smart____________ (to customize the documentation by making choices).

A

Texts, Lists, Links …?

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26
Q

Where are the details of the new order stored?

A

Record Viewer

27
Q

Is the patient record connected to the order record?

A

Yes

28
Q

Do the result-related details get stored in the patient record or order record?

A

..

29
Q

Referring to the diagram, is the result data stored in contact 1 or 2?

A

..

30
Q 
Harold’s prescription is nearing its end date. To reorder it in Medications & Orders, click:
A) Pencil 
B) Checkmark
C) Circle Arrow
D) Expand
A

Circle arrow

31
Q

True or False: To discontinue a medication, clear the Taking check box.

A

False

32
Q

Which of these are reasons why a medication warning can appear?
(Choose all that apply.)
A) The patient is allergic to the medication.
B) The patient has said in the past they do not want this prescription.
C) The patient has a similar current prescription.
D) The patient had a similar prescription that is expired.

A

A) The patient is allergic to the medication.

C) The patient has a similar current prescription.

33
Q

A physician signed an order for a point of care test and realized that it was the wrong test. It has not yet been resulted. How can she cancel this order? (Choose all that apply.)
A) In Medications & Orders in this encounter, click .
B) In Medications & Orders in any encounter for this patient, click .
C) In Enter/Edit Results in any encounter for this patient, click Cancel Order.
D) In Chart Review in any encounter for this patient, click Cancel Order.

A

A) In Medications & Orders in this encounter, click .

C) In Enter/Edit Results in any encounter for this patient, click Cancel Order.

34
Q 
Where do you document the administration details for a clinic-administered medication? (Select one.)
A) Immunizations activity
B) Order Review activity
C) MAR activity
D) Medication Review section
A

C) MAR activity

35
Q

A patient needs an immunization during today’s visit. Which of the following is the correct steps in the correct order? (Select one.)
A) Order the immunization > MAR > Document immunization administration
B) Order the immunization > Immunizations activity > Administer
C) Immunizations activity > Administer
D) Immunizations activity > Historical Admins

A

B) Order the immunization > Immunizations activity > Administer button

36
Q 
Which of the following represent open orders? (Choose all that apply.)
A) Normal
B) Future
C) Standing
D) High Priority
A

B) Future

C) Standing

37
Q 
In the Order Composer for a lab test, what field controls the ability to make it a Standing order? (Select one.)
A) Interval
B) Class
C) Expires
D) Status
A

D) Status

38
Q

In a SmartSet, the Antibiotics subsection has five items, but none of them are showing.
True or False: To see the items, expand the subsection.

A

True

39
Q

True or False: If you place orders in a SmartSet, you are limited only to those orders for the entire visit.

A

False

40
Q

True or False: The Express Lane activity uses SmartSets that are affected by programming that adds order search fields to the Medications and Orders sections.

A

True

41
Q

What is an example of why you would add a charge in Charge Capture? (Select one.)
A) To add a charge for the administration of a medication.
B) To select an LOS billing code for the encounter.
C) To order a lab test.
D) None of the above

A

A) To add a charge for the administration of a medication.

42
Q

Which of these can be ways to get procedure charges into Epic? (Choose all that apply.)
A) Use procedure documentation in NoteWriter.
B) Place an order.
C) Use the Charge Capture section.
D) Use a SmartText as your progress note.

A

A) Use procedure documentation in NoteWriter.
B) Place an order.
C) Use the Charge Capture section.

43
Q

Define Order composer

A

Appears when a user places orders and allows the user to enter information necessary for an order by clicking buttons or choosing options from selection lists. A user can access the Order Composer by clicking the Summary Sentence for an order.

44
Q

Medication-related: CAM (clinic-administered medication),

A

A medication that is administered by an clinician during an outpatient visit.

45
Q

Medication-related: MAR

A

Activity where clinicians can document the administration of a patient’s medications.

46
Q

Medication-related: Meds Due (in the schedule)

A

Meds Due column to your clinicians’ schedules allows them to see whether a patient has a medication administration due soon. The column displays an icon if the patient has persistent medications due one week before or after the current time (not the scheduled appointment time).

If a clinician sees this icon for a patient with an upcoming appointment, she might elect to administer the medication during the patient’s scheduled appointment rather than requiring the patient to come to the clinic again on the exact date the medication is due for administration. A clinician can double-click the Meds Due icon to open the patient’s encounter and go directly to the MAR.

47
Q

Order-related: Open order; status—Normal, Future, Standing; parent and child

A

A normal order is a procedure intended to be performed and documented within the same encounter in which it was ordered. This is not the case with future and standing orders.

Status = Future - An order for one item, to be released in the future. An imaging test or referral to specialty are examples. Icon: Purple Square

Status = Standing - Use this for multiples of an order, to be released in the future. Regularly repeated lab tests are an example. Standing order details include an Expires field and interval/count.

Normal order = single instance order; essentially a child order with no parent

Future/Standing order = one parent order that authorizes the order and one/more than one child order

Parent order is created when you sign an order.

Child orders are created behind the scenes.

A future order is a procedure intended to be performed once in a separate encounter. Perhaps during an encounter, a provider orders a lab test for a patient. However, the patient asks to come to the lab one week from now, after her business trip. In this situation, the provider can place an order and set it to a status of future.
Sometimes patients need tests done at regular intervals (for example, TSH tests every 3 months). Instead of placing individual orders for each test, providers can order the tests at the same time by setting the status to standing, and EpicCare will release (transmit) each order to its destination at regular intervals. (Alternatively, users can manually release each order.)

For both future and standing orders, the parent order never actually gets done. It is the child orders that will have the results attached to them. Therefore, when reporting, it is important to know how to determine which records are parents and which are children as well as which orders are normal. This will insure that you include the right records in your report.

If a user cancels a parent order, any released children will not be cancelled but no future children will be released. Canceling a child order has no impact on the parent or other children. All parent orders will eventually have child orders unless the parent is canceled before any children have been released.

48
Q

Define Preference List

A

A set of frequently used orders. Orders can be added to facility preference lists by members of your project team and you can also maintain your own personal preference list to include orders you have pre-configured based on your preferences.

49
Q

SmartSet-related: SmartSet; Express Lane

A

A documentation template. A group of orders and other elements, such as notes, chief complaints, SmartGroups, and levels of service, that are commonly used together to document a specific type of visit.

50
Q

Explain the impact of various order-related actions on order (ORD) records

A

Express Lane uses existing tools in EpicCare Ambulatory to create single-screen visits related to common chief complaints. This tool helps specialists quickly and easily document straightforward visits, and they still have access to other activities and navigators if a visit becomes more complex.

51
Q

Distinguish between CAMs versus outpatient-type medications and explain the impact of selecting one versus the other

A

CAM - A medication that is administered by an clinician during an outpatient visit.

Outpatient mode orders can be placed for an inpatient (ex: discharge medications for an admitted patient
preparing to leave the hospital) and Inpatient-mode orders can be placed in an outpatient encounter (ex: clinic-administered injection of Toradol).

When placing an order for a medication to be administered in the clinic, clinicians must choose the correct type of order to ensure that it becomes available on the MAR (Medication Administration Record activity), which is where the administration is documented. These ordering icons provide cues:
- Orders with outpatient details.
- Orders for which the in-clinic administration is documented in the MAR. These orders have inpatient details.
Note: While the icon is a syringe, clinic-administered
medications can be in any form: injection, tablets, patch, etc.

52
Q

The benefits of Express Lane and what causes it to appear

A

Express Lane combines two key elements on one screen:

  • A one-click way to mark allergies, problems, and medications as reviewed
  • Express Lane SmartSets and background programming that causes the SmartSets to have a common layout and special features

If various conditions such as specialty and chief complaint are evaluated as TRUE
when a workspace is being opened, Express Lane appears.
Because many Express Lane rules evaluate chief complaint (reason for visit), the activity does not launch until the provider accesses the workspace after the nurse is done rooming. If there is only one Express Lane SmartSet match, it can open automatically. Otherwise, the provider chooses from a list of Express Lanes.

53
Q

The impact of certain charting actions on billing

A

When providers do any of the following, they generate charges:
- Place orders
- Document using procedure documentation in NoteWriter (covered in the
Note-Writing chapter) or document in flowsheets (covered in a later chapter)
- Choose chargeable procedures in the Charge Capture section

Charge triggering is the process of clinical applications—called sources—sending information to the Charge Router that causes the generation of charge transactions. Those charges are then passed to the billing applications—called destinations—via the Charge Router.

54
Q

Documenting the __________ and __________ provided to the patient

A

care, services

55
Q

__________ patient care

A

planning

56
Q

Documenting __________ between the provider and any other health professional contributing to the patient’s care

A

communication

57
Q

Assisting in __________ the __________ interest of the patient and the health care providers responsible for the patient’s care

A

protecting

58
Q

If you had already filled in glucose values in Alyssa’s note, would the wildcards still be present?

A

No

59
Q

It wouldn’t make sense to copy that information into the new Phrase. How could you add it “untouched” to your user Phrase?

A

GREEN PLUS > SUMMON THE .HPIDM1FU SYSTEM PHRASE IN THE EDITOR > DELETE ALL OF IT EXCEPT THE PART YOU WANT

60
Q

A __________ is available in all SmartTool-enabled text boxes.

A

SmartPhrase

61
Q

A __________ can be _________ to certain types of SmartTool-enabled text boxes, and can be further restricted by factors such as patient _____ and _____

A

SmartText, restricted, age, and sex

62
Q

_________ and SmartPhrases often contain _________ (that automatically customize the documentation) and _________ (to customize the documentation by making choices).

A

SmartTexts, SmartLinks, Smart Lists

63
Q

In the SmartLists’ brackets, what is the purpose of the word(s) after the initial bracket?
After making the selections, are you able to identify the
words that were from that List?

A

The display text helps the end user know ahead of time the kinds of choices that will be offered on the list.
Yes

AMB100 (9 decks)

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