Text Quiz Questions Flashcards
How often should the encounter form be updated, and why?
At least twice a year, to ensure current code usage and reflect updates in coding guidelines.
Why should employee access to patient information be limited?
To ensure only authorized personnel can access data, reducing the risk of unauthorized access or data breaches.
What information is found in the Immunizations section of the EHR?
Date, type, dosage, and details of vaccines administered to the patient for easy reference and continuity of care.
What does the subjective section of a patient’s medical record include?
The patient’s chief complaint—why they sought medical attention.
What is the purpose of an admission face sheet?
To collect and verify a patient’s identity and administrative information, such as name, DOB, address, and insurance.
Besides HIPAA, who sets standards for access to PHI?
The U.S. Department of Health and Human Services (HHS).
Where is smoking status recorded in the EHR? Where are smoking cessation sessions recorded?
Smoking status = Medical history. Cessation sessions = Preventative care section.
What does EDI stand for and what is its purpose?
Electronic Data Interchange; allows providers to exchange billing information with insurance companies.
What is the chief complaint, and where must it be recorded?
The main reason for the physician visit; must be recorded in the EHR.
What is LOINC used for in EHR systems?
Logical Observation Identifiers Names and Codes; it standardizes lab and clinical observation names.
How is LOINC used in practice?
Example: Glucose test results may use LOINC code ‘2345-7’ for ‘Glucose in Blood.’ Lab results require provider signature unless pending.
What is stored in the legal data section of the EHR?
Legal documents such as patient consent forms and HIPAA documentation.
What is the purpose of health information and data management features in EHR?
To compare drug equivalency, safety, and cost before prescribing—ensuring best treatment options.
Under HIPAA, how long does a provider have to notify a patient of a PHI breach?
No later than 60 days after discovery; notification must be in writing.
Why is the CDC an important resource for providers?
It offers reliable, evidence-based patient education resources and health information.
What does evaluation and management refer to in EHR context?
It’s connected to determining the appropriate level of service for patient visits.
What is cataloging in the EHR system?
Inputting or uploading external documents or scanned files into their proper sections in the EHR.
What does a progress note contain?
Up-to-date information on the patient’s condition, diagnosis, and ongoing care.
What word should be used when correcting an error in the EHR?
The word ‘error’ must be recorded to indicate a correction was made.
Can personal information be shared when submitting to public health agencies?
No, personal information must remain confidential or anonymous.
What is a superbill or encounter sheet used for?
To document diagnosis and procedures for billing; leads to claim submission and follow-up.
What is a day sheet used for?
To close and review all patient transactions at the end of the day.
What system helps prevent duplicate prescriptions or orders?
Computerized Provider Order Entry (CPOE), which alerts for duplicates in real time.
Why are templates useful in EHR documentation?
They ensure accuracy, consistency, and completeness—saving time and improving data quality.
What is continuity of care?
The uninterrupted and coordinated care of patients across multiple healthcare providers, involving seamless sharing of medical records.
When does continuity of care typically occur?
When a patient sees more than one physician.
Are departments like ambulatory service and rehab considered inpatient?
No, these are not considered inpatient and do not use ICD-10-PCS codes.
What coding system is used for inpatient procedures?
ICD-10-PCS.
What is CPOE and what is its benefit?
Computerized Provider Order Entry; it helps prevent duplicate medical orders.
What are administrative safeguards in health IT?
Policies and procedures to protect electronic health data, including training, risk assessment, and incident response.
What is a data registry in healthcare?
A centralized system that collects and stores specific healthcare-related data for analysis and quality monitoring.
What are CPT codes used for?
To describe procedures for billing and documentation.
Are ICD-10-CM codes used in charge reports?
No, they are used to diagnose conditions but not typically in charge reports.
How do you code bilateral conditions in ICD-10-CM?
Use a bilateral code if available; otherwise, use separate codes for each side (right and left).
What happens if you bill a bilateral code when only one site is treated?
The system will generate a duplicate alert.
What must be in place when implementing a new EHR system?
A project champion and a committee for implementation.
What is subjective data in healthcare?
Patient-reported information, like pain.
What is objective data in healthcare?
Observable and measurable signs, like a fever.
What is Computer-Assisted Coding (CAC)?
A tool using AI to suggest codes based on documentation, speeding up the coding process.
What is the purpose of contingency testing and revision in EHRs?
To ensure the emergency response plan works and is updated based on test results.
What do Personal Health Records (PHRs) allow patients to do?
View their medical history, including past diagnoses, medications, allergies, and test results.
What is a Production by Provider report?
A report showing procedures each provider performed to track productivity and calculate profits.
Name a few abbreviations that should not be used in healthcare.
MSO, MSO4, MGS 04.
How is patient information stored in an EHR system?
In a secure and confidential database.
What form must a patient sign to allow medical records to be used for consultation?
Notice of Privacy Practices (NPP).
What form is required to transfer a patient’s medical records to a new physician?
Release of Information.
How long must medical records be retained in the U.S. under HIPAA?
Varies: typically 6-10 years, or 5 years for deceased patients (depending on state law).
What is an example of family history in patient records?
A father with heart disease.
What is an example of past surgical history?
The patient had a surgery in the past.
What is an example of history of present illness?
The patient is currently abusing a drug.
When must an Advanced Beneficiary Notice (ABN) be signed?
Before the procedure, not after.
What is a Master Patient Index (MPI)?
A centralized patient database that links and verifies patient identity across systems.
What is the MPI used for by an EHR specialist?
To accurately retrieve patient information from various sources.
What is the office manager’s role in scheduling?
To create procedures for efficient overlapping schedules and team coordination.
What does the office manager do for EHR system access?
Sets up role-based access to assign duties securely.
What date should be recorded as the date of service for a Holter monitor?
The date the patient returns the monitor and results are available—not the date it was issued.
Why is cloning progress notes in an EHR system potentially problematic?
It can result in outdated or incorrect documentation, affecting patient care and decision-making if not properly updated.
What is the difference between a diagnosis list and a problem list in an EHR?
A diagnosis list records conditions diagnosed by a provider, while a problem list includes issues prompting a visit, even if not diagnosed yet.
Can administrative personnel enter clinical data such as allergies or chief complaints into an EHR?
No, only clinicians can enter clinical information. Admin staff handle administrative fields only.
What is physician authorization in the context of EHR?
It’s permission given to a doctor to access a patient’s medical records to make informed treatment decisions.
What does MIPS stand for and who uses it?
Merit-Based Incentive Payment System, used by Medicare.
What is an intake form used for?
It collects essential patient information and chief complaints during the initial visit.
Why are protocols important in healthcare?
They guide providers in offering standardized, evidence-based treatment for medical conditions.
What should an EHR specialist do when reporting data for syndromic surveillance?
Submit reportable lab results to the Centers for Medicare and Medicaid Services (CMS).
How does Medicare typically split payment responsibility?
Medicare pays 80%, and the patient or secondary insurance pays 20%.
What section of the CPT coding book contains 99213?
The Evaluation and Management section.
What federal law requires secure backup of electronic health records?
HIPAA (Health Insurance Portability and Accountability Act).
Which federal office enforces HIPAA privacy and security rules?
The Office for Civil Rights (OCR).
What tool helps monitor patient location and status in a healthcare facility?
A patient tracker.
What is the best method for searching an established patient in the EHR system?
Use the last four digits of the patient’s Social Security number or date of birth.
What is the most reliable patient identifier in an EHR system?
Social Security number (SSN), with optional use of maiden or mother’s name.
How can an EHR specialist check for inappropriate use of protected health information?
Through the information systems activity review (audit trails and logs).
What is the best method to avoid data discrepancies in EHRs?
Use coded text data for standardized and accurate documentation.
What does coded data in EHRs improve?
Accuracy, consistency, and efficiency in documenting and sharing health information.
What are common uses of a patient portal?
Booking appointments, messaging providers, and viewing lab results.
What does CPT code 99213 represent?
An established patient outpatient visit requiring 2 of 3 components: expanded history, expanded exam, and straightforward decision-making, typically lasting 15 minutes.
What should you do before collecting a patient’s co-pay?
Check insurance eligibility to confirm co-pay, deductible, and other payment information.
What does SOAP stand for in clinical documentation?
Subjective, Objective, Assessment, Plan.
What are the two methods for making changes in EHR entries?
Reopen and edit the original entry or write an addendum, based on organizational policy.
Is an EMR a medical record that is stored digitally in a secure computer database within an organization or healthcare system?
✅ True – EMRs are digital versions of paper charts used in a single provider’s office.
If a child has two insurances from their parents, is the older parent’s insurance considered primary?
❌ False – The “Birthday Rule” states the parent whose birthday comes first in the calendar year is primary, regardless of age.
Does PHI stand for Protected Health Information and include things like a diagnosis or treatment?
✅ True – PHI includes any health information tied to an individual, such as diagnoses and procedures.
When creating templates, should x-rays go under radiology, CBC panels under lab, and decision-making under progress notes?
✅ True – Each element should be accurately categorized within the EHR.
Is a patient reporting chest pain considered objective data?
❌ False – Pain is subjective since it is reported by the patient and cannot be directly measured.
Does the “S” in SOAP notes stand for subjective information provided by the patient?
✅ True – Subjective notes include symptoms and personal experiences described by the patient.
Are Category II CPT codes used for performance measurement and preventive care like smoking cessation or blood pressure monitoring?
✅ True – Category II codes are used to track performance and are optional (not for billing).
Does patient flow refer only to physical movement through a facility?
❌ False – Patient flow includes care delivery, internal processes, and resources, not just movement.
If a diagnosis includes both acute and chronic conditions, should you use one ICD-10-CM code if one exists for both?
✅ True – If a combination code exists, it should be used instead of coding separately.
Do ICD-10-CM codes start with a letter and have a decimal after the third character?
✅ True – Codes like “M54.5” follow this structure.
Does the CPT manual include Evaluation & Management codes and lab codes?
✅ True – The CPT book includes both E/M and laboratory codes.
Is smoking and alcohol use documented in the Review of Systems (ROS) section?
❌ False – This is typically documented in the History of Present Illness (HPI) or Social History section.
Do providers have 60 days to notify patients after discovering a PHI breach?
✅ True – HIPAA requires notification within 60 days of discovery.
Are the two main types of Clinical Decision Support Systems (CDSS) knowledge-based and non-knowledge-based systems?
✅ True – Knowledge-based systems use rules, while non-knowledge-based systems may use AI or pattern recognition.
Can Clinical Decision Support tools reduce errors and improve satisfaction when used correctly?
✅ True – Properly designed CDSS tools enhance diagnosis accuracy and workflow efficiency.
Is Evidence-Based Practice important because it ensures care is based on the best available evidence?
✅ True – EBP improves patient outcomes and relies on research, guidelines, and expert consensus.
