Quiz 1 Flashcards
Which of the following actions by an EHR specialist exhibits professional standards of care as it pertains to the HIPPA Privacy Rule?
Sharing clinical information between coworkers in a public area
Accessing an 19-year-old patient’s information for their parent
Disclosing a patient’s clinical information following a court order
Printing clinical information for a patient’s friend
Disclosing a patient’s clinical information following a court order
Under HiPAA Privacy Rule, which of the following individuals can be given directory information about the patient without asking staff for a specific patient’s name?
A patient’s relative
A clergy person
A patient’s friend
Law enforcement personnel
A clergy person
How frequently should a health care organization obtain permission from a patient to release protected health information (PHI) for processing insurance claims?
Each calendar year
Every fiscal year
Once
Every visit
Once
An EHR specialist is assisting a new billing specialist with entering diagnosis codes for reimbursement purposes. While entering the codes, which of the following statements made by the billing specialist should the EHR specialist identify as being correct?
The comorbidity is entered as the primary diagnosis code
It is not allowed to use diagnosis code from a past patient visit
The primary diagnosis is the reason the patient came to the hospital
A condition existing concurrently with the primary diagnosis should not be billed
The primary diagnosis is the reason the patient came to the hospital
Which of the following information documented by a provider during a patient’s visit should be included on the electronic superbill?
Patient’s past medical history
Laboratory results
Diagnosis codes
SOAP notes
Diagnosis codes
An EHR specialist is assisting a patient who wants to access the patient education material for assistance in smoking cessation. Which of the following documents are accessible in the patient education area of the patient portal?
Progress notes from previous visits
Radiology report
Scheduling for smoking cessation classes
Information from the American Cancer Society
Information from the American Cancer Society
An EHR specialist is assisting with providing training to a newly hired provider. Which of the following statements should the EHR specialist make regarding the e-prescribing feature of the EHR?
The e-prescription is copied to a secure email to be transmitted to the pharmacy
The pharmacist enters the e-prescription into the EHR
A renewal authorization can be transmitted using this feature
The receptionist can use e-prescriptions to reorder expired medications
A renewal authorization can be transmitted using this feature
A billing specialist is preparing to electronically submit charges to a patient’s third-party payer for a completed procedure. Which of the following actions should the billing specialist perform before applying the charges to the patient’s account?
Review the charges to verify documentation in the patient’s record
Ensure a paper encounter form was completed to verify the charges
Confirm that the internal coding audit has reviewed the bill for accuracy
Verify the patient’s insurance to ensure billing accuracy
Review the charges to verify documentation in the patient’s record
A medical coder is leaving a practice for a new position at a different facility. Which of the following actions should the EHR specialist take to prevent unauthorized access to the system?
Assign a new password to the coder’s account
Terminate the coder’s account
Have the coder sign a contract stating they will not access the account
Periodically audit the account to ensure it has not been accessed
Terminate the coder’s account
Which of the following is a computer protocol that specifically supports both clinical and administrative health data?
Digital Imaging and Communications in Medicine (DICOM)
Health Level 7
Clinical Data Interchange Standards Consortium (CDISC)
Health Level 7
An EHR specialist is assisting in collecting information for a workflow analysis. Which of the following actions should the EHR specialist take?
Use a vendor to conduct the workflow analysis
Ask staff members to write detailed descriptions of the responsibilities of their positions
Designate one contact person to coordinate the workflow analysis of staff members
Create new forms to be included in the workflow analysis
Ask staff members to write detailed descriptions of the responsibilities of their positions
An EHR specialist is assisting with training about an event of unexpected downtime of the EHR. Which of the following statements from a staff member indicates an understanding about submitting claims during a downtime procedure?
I can wait for the system to recover before submitting a claim
I can submit a paper claim during downtime
I can access claims via a web-based system during downtime
I can submit a paper claim during downtime
An eHR specialist is training new front desk staff about sending referral records securely. A staff member asks, “What if I get called away while working on a record and forget to close the chart?” Which of the following responses should the EHR specialist make?
You’d better not do that. You will be let go because that is a violation of patient confidentiality.
Nobody will see it. Only employees are allowed to be back at the desk
It has a security feature. If you step away for a couple of minutes it will log you out automatically
The system tracks everything you do. If you leave your workstation too much, you’ll have to repeat some training
It has a security feature. If you step away for a couple of minutes it will log you out automatically
An EHR specialist should recognize that which of the following terms is used to describe any sample of tissue or fluid collected from a patient at the point of care for testing purposes?
Venipuncture
Biopsy
Specimen
Cytology
Specimen
An EHR specialist is organizing an in-service for staff members about securing personal mobile devices for work-related use. Which of the following instructions should the EHR specialist include.
Enable file-sharing applications
Disable built-in encryption systems
Enable a firewall
Disable remote wiping for devices
Enable a firewall
In the event of a computer antivirus update failure, which of the following will mitigate security threats such as a possible data breach?
Documentation requirements
Physical safeguards
Administrative safeguards
Permitted disclosures
Physical safeguards
An EHR specialist is assisting the unit staff during a go-live session for implementation of the EHR system. The EHR specialist overhears a nursing assistant starting to another staff member, “I forgot my password. Can you log in so I can chart this information right now?” Which of the following actions should the EHR specialist take?
Report the incident to another staff member
Help the nursing assistant obtain a new password
Document the information for the nursing assistant
Help the nursing assistant obtain a new password
Insurance verification takes place in which of the following phases of the revenue cycle?
After receiving the remittance advice
When submitting the claim
During the encounter
Preregistration
Preregistration
A healthcare organization has added encoding software to its EHR. How does this affect the process for internal audits?
Internal audits should be conducted to ensure that all procedures are coded correctly
Coding can be excluded from internal audits after the software is installed
Internal audits can be eliminated by the use of code assist software
Internal audits can be delegated to clinical personnel after code assist software is implemented
Internal audits should be conducted to ensure that all procedures are coded correctly
A patient witnesses a provider reviewing records using a laptop computer. The patient expresses concern about the security of this practice. Which of the following responses should a clinic staff member make sure to reassure the patient regarding the provider’s security practices?
Transmissions to all devices used by our staff take place over a virtual private network
The practice’s mobile devices can only be used in the office.
Computer technicians update our EHR software regularly
Transmissions to all devices used by our staff take place over a virtual private network
An EHR specialist is verifying the accuracy of a production by procedure report. The EHR specialist should identify that which of the following is a purpose of this report?
To schedule appointments and staff
To calculate the amount of revenue generated
To determine the reimbursement amounts by third-party payers
To sort services by provider
To calculate the amount of revenue generated
A patient asks an EHR specialist to provide them with a statement that shows their appointment dates and detailed charges. Which of the following documents should the EHR specialist provide to the patient?
Itemized statement
Remittance advice
Payment plan
Fee schedule
Itemized statement
A physical therapist asks an EHR specialist for assistance with entering a new e-prescription in the EHR. Which of the following statements should the EHR specialist make?
The provider will need to enter the e-prescription
The pharmacist will need to enter the e-prescription
The registered nurse will need to enter the e-prescription
The office manager will need to enter the e-prescription
The provider will need to enter the e-prescription
Which of the following methods can patients use to enter data into the record themselves?
Email
Check-in kiosk
Telephone
Mail
Check-in kiosk
A cardiologist asks the EHR specialist if there is a way to develop a template for heart transplants with information that can be searched. Which of the following types of data would go in this template?
Diagnostic images
Text files
Scanned documents
Coded data
Coded data
Which of the following reports should the EHR specialist create for a practice manager to provide information for assisting in the scheduling of staff?
Day sheet report
Remittance advice report
Billing/payment status report
Production by provider report
Production by provider report
Which of the following patient information entered and verified during admission to the facility will likely generate an alert to the provider when using the computerized provider order entry system (CPOE)?
Known medication allergies
Last surgical procedure
Immunization history
Family medical history
Known medication allergies
A nurse in an infusion clinic asks the EHR specialist for assistance with discharging a patient who will soon be returning to receive their first infusion of a new medication. Which of the following actions should the EHR specialist take when providing patient education materials?
Ask the patient for their telephone numbers to set up an education appointment
Suggest that the patient go online to read about infusion reactions
Show the patient how to access the information in the patient portal
Tell the patient they will receive the education materials in the mail
Show the patient how to access the information in the patient portal
An EHR specialist is working with an office manager to increase the efficiency of a healthcare organization. Which of the following should the EHR specialist understand is part of a successful overlapping schedule?
Asking the patient for insurance information
Inquiring about patient history
Defining roles within the office
Determining the type of appointment
Determining the type of appointment
A facility staff member asks an EHR specialist what to do if a visitor requests an adult patient’s health information. Under which of the following circumstances would the information be released to a visitor?
Information should only be released to a family member
Information should only be released verbally
Only de-identified information should be released to the visitor
Information should only be released with specific patient authorization
Information should only be released with specific patient authorization
Which of the following provides a snapshot of how much money is due to a facility from third-party payers and patients in a computerized practice management system?
Deposit report
Aging A/R report
Patient ledger
Day sheet
Aging A/R report
An EHR specialist receives records transmitted from a hospital about an established patient’s recent admission. The EHR specialist identifies potential discrepancies in the patient’s past medical history. Which of the following actions should the EHR specialist take?
Contact the hospital to update their records
Charge the EHR record to reflect the hospital’s data
Reconcile the patient’s hospital record with the office record
Request a co-worker review the records
Reconcile the patient’s hospital record with the office record
An EHR specialist is performing an internal audit of the EHR records and discovers improper billing documentation that suggests potential fraud or abuse in accounts of patients who have a private third-party payer. Which of the following agencies should handle this type of inquiry?
Centers for Medicare and Medicaid Services (CMS)
Office of the National Coordinator for Health Information Technology (ONC)
Office of Inspector General (OIG)
The Joint Commission (TJC)
Office of Inspector General (OIG)
An EHR specialist is reviewing the chart of a patient who is listed as self-pay. Which of the following notes in the chart would indicate to the EHR specialist that the client has Medicare coverage?
The patient is receiving renal dialysis for end-stage renal disease
The patient has had a coronary artery stent
The patient is a federal employee
The patient’s income is 150% of the federal poverty level
The patient is receiving renal dialysis for end-stage renal disease
A new medical group is planning to hire a privately owned information technology company to manage its IT operations. Which of the following should the medical practice take to ensure the IT company will maintain the security of all data transmissions?
Obtain a copy of the IT company’s procedure manual
Confirm they are certified by the Centers for Medicare and Medicaid Services
Review the IT company’s record filed with its state regulatory agency
Enter into a business associates contract with the IT contractors
Confirm they are certified by the Centers for Medicare and Medicaid Services
An EHR specialist is assisting a clinical coder with code verification and notes that there is insufficient information in the patient record to support diagnosis coding. Which of the following actions should the EHR specialist instruct the coder to take to request additional documentation from the health care provider?
Send a provider query
Telephone the provider
Text message the provider
Send the provider a primary source request
Send a provider query
An EHR specialist is working with an ophthalmologist. Which of the following types of templates should the EHR specialist create for use during detailed eye examination?
Specialized template
Progress note template
Treatment plan template
Problem list template
Specialized template
A facility’s EHR software reflects a change in a patient’s baseline platelet count. Which of the following methods of notification does the software use to inform the provider?
An automatic alert message
An email
A flag in the patient’s record
A phone call
An automatic alert message
Which of the following functions of the EHR allows coders to query health care providers for clarification during a patient’s inpatient hospitalization?
Work-list reports
Concurrent coding
Problem lists
Care plans
Concurrent coding
Which of the following methods should an EHR specialist use to make changes or corrections to entries in the EHR?
Write an addendum to the existing entry
Delete the original entry and insert a new entry
Reopen the encounter and change the original entry
Contact the health information management team to request access for a correction
Write an addendum to the existing entry
An EHR specialist receives a call from the parent of a n 18-year-old patient asking why their child was seen at the office last week. Which of the following actions should the EHR specialist take?
Ask for the patient’s name and date of birth and give the requested information
Check the patient’s medical record for a release of information form to determine if the parent is listed
Notify the patient’s provider to get permission to give the requested information the parent
Check the patient’s medical record for a release of information form to determine if the parent is listed
An EHR specialist is preparing to enter information into a patient’s record. The EHR specialist has confirmed the patient’s medical record number. Which of the following patient identifiers should the EHR specialist use as a second identifier to verify the patient’s identity?
Patient’s address
Mother’s maiden name
Name of patient’s nearest relative
Name of patient’s insurance provider
Patient’s address
Which of the following actions should a patient take to authorize a participating health care organization to receive payment from a third-party payer?
Verbally authorize assignment of benefits to the health care organization
Provide a signature for assignment of benefits to the healthcare organization
Contact the third-party payer to assign benefits to the health care organization
Provide a signature for assignment of benefits to the healthcare organization
An EHR specialist is assisting with providing training for a group of admission clerks about an EHR system. In which of the following data sections of the record should the EHR specialist instruct the group to enter a patient’s HIPPA forms?
Legal data
Clinical data
Financial data
Administrative data
Legal data
An EHR specialist is assisting a facility in implementing a recent upgrade to the EHR system. Which of the following would be the best question for the EHR specialist to ask in preparing for implementation?
How many other facilities have completed the upgrade?
What is the timeline for these changes?
What is the facility’s cost for the upgrade?
What is the timeline for these changes?
An EHR specialist is assisting a provider with finding codes for a dentistry procedure. Which of the following classification systems should the health record applicant use?
CDT codes
IDC-10-PCS codes
CPT codes
DSM-5
CDT codes
An EHR specialist is assisting a provider to enter a clinical order to obtain three blood draws. Which of the following components of the EHR should the EHR specialist assist the provider to access?
CDSS
Billing
Schedules
CPOE
CPOE
A provider orders a laboratory test in the EHR. Which of the following describes the way laboratory specimens are labeled and tracked?
The specimens are delivered to the laboratory, where the labels will be generated when the laboratory personnel change their status to “received”
The phlebotomist writes three unique patient identifiers on the specimen container immediately after the specimen is collected
Labels are automatically printed at the point of care as part of the automatic requisition process
Labels are automatically printed at the point of care as part of the automatic requisition process
An EHR specialist is developing templates for a facility’s EHR database. In which of the following sections of the EHR should the specialist place progress notes?
Legal data
Clinical data
Financial data
Administrative data
Clinical data
An EHR specialist is assisting a provider with entering a patient’s admission data into the health record. In which of the following areas of the EHR should the specialist document the patient’s blood pressure?
Problem list
Diagnosis list
Physical examination
History of present illness
Physical examination
Which of the following patient history findings should be automatically forwarded to the state public health agency?
Iron-deficiency anemia
Saliva sample positive for measles
Positive urine drug screen for a pregnant patient
Blood test indicating kidney failure
Saliva sample positive for measles
An EHR specialist is updating patient information in the electronic health record (EHR). Which of the following is an example of administrative data that can be found in the EHR?
Imaging test results
Demographic information
Surgical reports
Immunization records
Demographic information
Which of the following security management processes is performed first by a covered entity to determine threats to the confidentiality, integrity, and availability of protected health information (PHI)?
Risk management
Sanction policy
Risk analysis
Information system activity review
Risk analysis
An EHR specialist is assisting a clinic nurse with data entry related to a well-baby check-up. When entering the infant’s weight into the record, the EHR specialist should understand that the data would result in which of the following types of documentation?
Assessment
Growth chart
Superbill
Review of systems
Growth chart
An EHR specialist should identify which of the following members of the health care team can be granted remote access to EHRs?
Provider
Phlebotomy technician
Medical assistant
EKG technician
Provider
An EHR specialist is assisting a medical assistant with entering a patient’s ongoing temperature measurements into the EHR. The EHR specialist should understand that the result is documented in which of the following locations?
Review of systems
Flow sheet
PRogress note
Encounter form
Flow sheet
An EHR specialist is providing a patient with information about the patient portal. Which of the following statements by the patient indicates an understanding of the patient portal?
“I can access my medical records without the use of a username or password”
“I can communicate with other patients”
“I can schedule my own appointments”
“I can update my preferred care plan”
“I can schedule my own appointments”
An EHR specialist is assisting with obtaining the history of a patient. The EHR specialist should document which of the following information in the history section of the progress note?
Temperature
Medication list
Cognitive status
Review of symptoms
Medication list
Which of the following is considered protected health information?
The patient’s place of birth
The patient’s zip code
The patient’s diagnosis
The patient’s age
The patient’s diagnosis
An EHR specialist is assisting the provider in searching for data in a patient record. When searching for “ankle injury”, no entry is identified. In additional searches, entries are located by searching “ankle sprain” and “twisted ankle”. The EHR specialist should recognize that the data can be reconciled by using which of the following types of data?
Text data
Coded data
Fielded data
Digital image data
Coded data
Which of the following actions should a facility take to ensure security compliance and protect EHRs from unauthorized access?
Issue unique user identifications for use of computers
Disable automatic logoff from computers during working hours
Allow staff to use file-sharing applications on their mobile devices
Deactivate remote data wiping on mobile devices
Issue unique user identifications for use of computers
Which of the following forms is used to capture the diagnoses and charges related to a patient visit prior to submitting them for reimbursement?
CMS-1500 form
Remittance form
Encounter form
UB-04 form
Encounter form
An EHR specialist is verifying if a laboratory test the provider ordered is covered under the patient’s insurance contract. Which of the following steps is the EHR specialist completing?
Preauthorization
Precertification
Predetermination
Preregistration
Precertification
An eHR specialist is preparing to perform a statistical review of infection rates at a facility for quality of improvement purposes. To compare statistical data with other facilities, the EHR system should be integrated with which of the following?
Master Patient Index (MPI)
Clinical Decision Support System (CDSS)
Uniform Ambulatory Care Data Set (UACDS)
Clinical Decision Support System (CDSS)
Which of the following patient portal features meets the criteria for patient engagement as part of EHR incentive programs?
Request my appointment
Review medical history
Send clinical summaries
Get medical advice
Send clinical summaries
An EHR specialist should identify that which of the following is the process for converting text into code for secure transmission?
Entity authentication
Data backup plan
Integrity controls
Encryption
Encryption
An EHR specialist is assisting a records clerk with the handling of a removable media device containing protected health information (PHI). Which of the following actions should the EHR specialist tell the clerk to take to prevent security risk?
Place the device in an allocated area for reuse
Discard the device in the front office trash bin
Remove protected health information from the device
MAke a copy of the information on the device to store in an offsite location
Remove protected health information from the device
Which of the following is an administrative safeguard used to ensure the security of electronic medical records?
Data backup and storage
Encryption
Password management
Automatic logoff
Password management
In which of the following sections should an EHR specialist look to find a patient’s most recent weight measurement?
Family history
Social history
Physical examination
Demographic
Physical examination
An EHR specialist is training clinical coders about how to use a new clinical encoder software program. Which of the following should the EHR specialist include as a benefit of the clinical encoder program?
Replaces the code books
Helps coding professionals navigate coding pathways
Automates the entire coding process
Eliminates coding errors
Helps coding professionals navigate coding pathways
Which of the following information is required from a prescribing provider to complete an electronic laboratory order?
Medical history
Diagnosis code
Patient’s weight
Patient’s allergies
Diagnosis code
A medical office receives an imaging report via fax machine and an EHR specialist scans it into the patient’s record. This is an example of which of the following methods of data collection?
Manual
Interfacing
Automated
Interoperable
Manual
An EHR specialist is developing a template to create authorizations for the health clinic to send immunization records for college-bound patients to their respective universities. To remain compliant with the Privacy Rule, the EHR specialist should understand that which of the following items is required to be on the template?
Date signed
Time signed
Date of birth
Date signed
An EHR specialist is instructing the parent of a pediatric patient about the patient education feature in the patient portal. The parent asks, “How do I send this information to my child’s step-parent?” Which of the following actions should the EHR specialist take?
Ask about custody rights and mention setting limits on who can access the child’s information
Talk about best practices related to sending information securely
Demonstrate how to send information from the patient portal
Guide the parent through the process of completing authorization to release medical records
Demonstrate how to send information from the patient portal
In Which of the following sections should an EHR specialist locate objective findings from a patient’s previous visit?
Past medical history
Social history
Chief complaint
Review of systems
Past medical history
Which of the following methods should an EHR specialist use to make changes or corrections to entries in the EHR?
Write an addendum to the existing entry
Delete the original entry and insert a new entry
Reopen the encounter and change the original entry
Contact the health information management team to request access for a correction
Write an addendum to the existing entry
