Medical Office Computer Applications Flashcards
Which of these is a safeguard put in place to help secure access to Electronic Health Record information?
A. Protected passwords
B. E- prescriptions
C. Legalized hacking systems
D. Special note documentation areas
A. Protected passwords
Rationale
When storing protected health information in an electronic format, it is important to protect user access. One of the major safeguards put in place to help secure access to the EHR information is protected passwords. Each user, or set of users, should be given passwords that are protected and confidential. E-prescribing is a way of routing prescriptions directly to a pharmacy (it is a function within an EHR format, not an accessibility safeguard). Hacking is an activity that can gain users illegal access to a system and is a federal crime. Special note documentation areas are within an EHR, allowing special notes to be recorded (possibly phone calls, messages, legal correspondence, surgical notes, etc.).
A physician asks the medical assistant to enter data into a patient’s electronic medical record using the SOAP format. What does the “P” represent?
A. Physician name
B. Problem
C. Progress
D. Plan
D. Plan
Rationale
The SOAP format is a commonly used system for documentation in medical charts since it offers a complete, consistent, and organized format for information management and retrieval. S=Subjective, O=Objective, A= Assessment, and P=Plan. Subjective information includes statements about symptoms, social history, how the patient feels, etc. Objective information includes actual data generated from examination, x-rays, laboratory reports, etc. The Assessment content is based on the physician’s analysis of the subjective and objective information, which would include a diagnosis. The Plan portion of the record will contain the treatment plan and course of follow-up action (next appointment, medications prescribed, additional testing, etc.).
Which of these would be recorded under the “S” in a patient’s EHR if using the SOAP format? (Select the 4 correct responses)
A. Sodium level
B. Symptoms
C. Social history
D. Feeling of fatigue
E. History of present complaint
B. Symptoms
C. Social history
D. Feeling of fatigue
E. History of present complaint
Rationale
The SOAP format is a commonly used system for documentation in medical charts since it offers a complete, consistent, and organized format for information management and retrieval. S=Subjective, O=Objective, A= Assessment, and P=Plan. Subjective information includes statements about symptoms, social history, how the patient feels, etc. Objective information includes actual data generated from examination, x-rays, laboratory reports, etc. The Assessment content is based on the physician’s analysis of the subjective and objective information, which would include a diagnosis. The Plan portion of the record will contain the treatment plan and course of follow-up action (next appointment, medications prescribed, additional testing, etc.).
Where is the diagnosis entered under the SOAP format?
A. S
B. O
C. A
D. P
A
(A= ASSESSEMENT)
S= SUBJECTIVE, O=OBJECTIVE, A= ASSESSMENT, and P= PLAN.
Rationale
The SOAP format is a commonly used system for documentation in medical charts since it offers a complete, consistent, and organized format for information management and retrieval. S=Subjective, O=Objective, A= Assessment, and P=Plan. Subjective information includes statements about symptoms, social history, how the patient feels, etc. Objective information includes actual data generated from examination, x-rays, laboratory reports, etc. The Assessment content is based on the physician’s analysis of the subjective and objective information, which would include a diagnosis. The Plan portion of the record will contain the treatment plan and course of follow-up action (next appointment, medications prescribed, additional testing, etc.).
IF a physician places a patient on high blood pressure medication after a routine physical, where would it be recorded using the SOAP format?
A. S
B. O
C. A
D. P
P.
P=PLAN
Rationale
The SOAP format is a commonly used system for documentation in medical charts since it offers a complete, consistent, and organized format for information management and retrieval. S=Subjective, O=Objective, A= Assessment, and P=Plan. Subjective information includes statements about symptoms, social history, how the patient feels, etc. Objective information includes actual data generated from examination, x-rays, laboratory reports, etc. The Assessment content is based on the physician’s analysis of the subjective and objective information, which would include a diagnosis. The Plan portion of the record will contain the treatment plan and course of follow-up action (next appointment, medications prescribed, additional testing, etc.).
A medical assistant is taking a patient’s history and entering it directly into the EHR. The patient’s main reason for seeing the doctor is a severe migraine headache. If this office uses the CHEDDER format of documentation, under which letter would this information be entered?
A. D
B. C
C. R
D. A
C.
(C= CHIEF COMPLAINT)
C= chief complaint, H= history of presenting illness, E= Examination, D= Details, D= drugs and dosages, A= assessment, and R=return visit information/referral.
Rationale
The CHEDDAR format is a commonly used system for documentation in medical charts since it offers a complete, consistent, and organized format for information management and retrieval. C=Chief complaint, H=History of presenting illness, E=Examination, D=Details, D=Drugs and dosages, A=Assessment, and R=Return visit information/referral.
Which of the following are internet search engines? (Select the three (3) correct answers.)
A. Bing
B. Linux
C. Google
D. Windows XP
E. Yahoo
Bing, Google, Yahoo
A, C, E
While reconciling electronic payments at the end of the day, the medical assistant leaves the front desk to help a coworker. When the medical assistant returns, the computer screen is blank. There is evidence that the office cleaning crew has vacuumed and emptied the trash around the front desk. How should the medical assistant initially troubleshoot this issue? ( select the four correct answer below.)
A. Click the mouse.
B. Press a key on the keyboard.
C. Replace the monitor connector cable.
D. Verify that the computer is plugged in and turned on.
E. Check to see that the monitor is connected to the computer.
A, B, D, E
Click the mouse, Press a key on the keyboard, Verify that the computer is plugged in and turned on, Check to see that the monitor is connected to the computer.
Rationale
There are several reasons why a computer screen may be blank. Many offices have software settings that send the computer into sleep mode after a specified time of inactivity. Clicking the mouse or pressing a key on the keyboard will “wake up” the computer so users can resume activity. In this scenario, the cleaning crew could have accidentally bumped some of the connections, therefore making it logical to check the connections, plug ins, and power indicators. These are all very basic troubleshooting methods for a blank screen. The monitor cable is probably fine because it was working properly a few moments prior. If it was damaged, it could be detected when checking the connection.
Which peripheral office device is used to capture images for display or editing on a computer?
A. Copy machine
B. Printer
C. Scanner
D. Mouse
C. Scanner
Rationale
Sometimes it is useful to display and edit images on a computer. A scanner will capture images (photographs, documents, etc.) and convert them to digital formats that can be stored or otherwise manipulated on a computer. Printers and copy machines produce a hard copy of a document, photo, etc. (some printers and copy machines also have scanning features, making them multi-function devices). The mouse is used to move the cursor and navigate the computer screen.
