Study Guide

Question 1

The progress note includes such

Answer 1

Details as the physical exam and the history of present illness

Question 2

Moving to an electronic health record lessens the need for

Answer 2

Many office supplies used to house records, such as Folders and clips for each file

Question 3

Because of the immediate availability of data about each patient, medication errors have

Answer 3

Decreased with the use of EHR

Question 4

The 1st step of the information chain in electronic system is

Answer 4

Before any information can be documented, the patient must 1st make an appointment.

Question 5

EHR clinic is a combined

Answer 5

Practice management EHR software

Question 6

A patient’s age is not

Answer 6

Clinical information

Question 7

Before making an appointment, the receptionist needs to know the condition or symptoms for which the patient is being seen before determining

Answer 7

The amount of time allotted for each appointment

Question 8

The health information management and information technology departments are

Answer 8

Closely related

Question 9

Registered health information administrator (RHIA) professionals have the education and background necessary to hold positions such as

Answer 9

Cancer registrar, privacy officer, software analyst, or compliance officer

Question 10

Protected health information is any information, such as

Answer 10

Name, address, phone number, or medical information, that identifies the patient

Question 11

Registration that takes place from the same department or area as known as

Answer 11

centralized or (central) registration

Question 12

Regardless of the number of times the patient is seen, he/she is entered only

Answer 12

One time in the MPI

Question 13

The name of the form should be related to its purpose, such as

Answer 13

“patient history” or” physical exam”

Question 14

Commonly, the box in which electronic data is entered is known as

Answer 14

A field

Question 15

A review of Systems is the

Answer 15

Collection of subjective symptoms related to a patient’s body systems

Question 16

Blood pressure is an objective finding it would not be included in the

Answer 16

History of the present illness

Question 17

A person hired to manually record a physician’s recorded spoken words is known as a

Answer 17

Transcriptionist

Question 18

The review of systems will cover the information

Answer 18

Documented on a medical history form

Question 19

One piece of an annual exam is a complete review of each body system. A review of systems is an

Answer 19

Inventory or subjective symptoms experienced by a patient for each body system

Question 20

Only the sections of the history of present illness that apply to a patient’s chief complaint are

Answer 20

Collected At a visit

Question 21

Knowingly billing for unnecessary or non occurring services constitutes

Answer 21

As fraud

Question 22

The fee schedule is the document that includes

Answer 22

The fee charged for each service rendered in a medical practice

Question 23

HCPCS level 2 codes are used to

Answer 23

Code supplies

Question 24

The medical history is documented on the patient’s health record, but not on the

Answer 24

Superbill

Question 25

It is the office of inspector general that is in charge with

Answer 25

Investigating cases of suspected fraud or abuse

Question 26

It is through the ACA that reimbursement methodology has become tied to

Answer 26

Quality and coordination of care

Question 27

It is possible to have too many flag alerts set up in the EHR clinic, so use

Answer 27

Caution to only create critical flags

Question 28

A patient who often misses appointments, will have an alert set to appear on her record: this alert is known as

Answer 28

A flag

Question 29

Providers must provide proof of citizenship during the

Answer 29

Credentialing process

Question 30

Care providers typically agree to lower rates of reimbursement when contracting with

Answer 30

Insurance carriers

Question 31

Custom reports have at least

Answer 31

2 variables

Question 32

A narrowing detail such as “patients 30 years or older” is called

Answer 32

A filter

Question 33

Any emails containing protected health information should be

Answer 33

Encrypted for security

Question 34

HIPPA regulations require that EHR systems store and transmit information in the form of

Answer 34

Codes, rather than text based (written out) descriptions

Question 35

An EHR must be certified to comply with

Answer 35

Promoting interoperability standards

Question 36

Paper forms need to be logical for Ease of

Answer 36

Completion

Question 37

A patient’s histories are gathered by

Answer 37

Asking the patient questions and/or having the patient or legal guardian complete a medical/surgical history form

Question 38

Discrepancies and information are noted in

Answer 38

A details Box

Question 39

It is critical to document any discrepancies in

Answer 39

Patient information

Question 40

BMI stands for

Answer 40

Body mass index

Question 41

The quality of a scanned (digital) image is known as

Answer 41

The resolution

Question 42

It is a great idea to plan ahead and ensure that orders are completed in a

Answer 42

Timely manner, however ordering a desk calendar is low priority

Question 43

Task lists allow a user to

Answer 43

Keep track of tasks needed to be completed

Question 44

Flags give healthcare professionals

Answer 44

Reminders about individual patients that they would not otherwise remember

Question 45

A default Value automatically appears within a

Answer 45

Field since that particular valve is common

Question 46

A copay (copayment) is the

Answer 46

Fixed amount that is collected at the time Of a visit for most patients covered under managed care plans

Question 47

The appointment is the 1st step in building the

Answer 47

Claim