Week 1 &2 Quiz Flashcards

1
Q

How is a correction made to an electronic health record?

A

The incorrect entry is corrected and the original entry is hidden from view but is still retrievable

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2
Q

EHR clinic uses a single __ to store administrative and clinical data on each patient

A

Database

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3
Q

Dr. Evans office has computerized the following functions, appointment scheduling, charge capture, collections, and reporting. These are all found in which type of software?

A

Practice management

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4
Q

(Picture) under which category would the patients marital status be listed?

A

Social history

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5
Q

Christine Simmons arrived for her appointment with Dr. Shumaker 20 min ago. The Healthcare professional has just left the room after taking Christine’s vital signs, weight and a brief history of present illness. What will the next step in Christine’s flow through the overall process?

A

The care provider will see the patient

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6
Q

The health information manager and the __ work closely to ensure a fully operational, secure electronic health record that meets the need of all users within the facility?

A

Information technology manager/ officer

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7
Q

Research has shown what relation to the use of an EHR

A

Care providers have embraced the use of EHR software willingly

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8
Q

You are a healthcare professional At SBHC and you have just shown a patient Mrs. Clark to the checkout desk where the billing coordinator had just taken the encounter form Supebill for the visit. Dr.Daniels came to the window and stated that Mrs. Clark left the exam room before receiving her flu shot what will occur in this case?

A

Mrs. Clark will be taken back to the exam room she will be given the injection by the health care professional who will document it in Mrs. clark’s record and will then update the encounter form then reflect the charges for the flu shot at that point miss Clark will return to the checkout desk.

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9
Q

In order to send and accept diagnosis codes using ICP-10-CM Which version of the Hippa code set rules was effective as of January 1st 2012

A

Version 5010

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10
Q

You are a registrar in the admitting office of a hospital a patient presents to register for an outpatient laboratory test what will you first access to determine if that patient has ever been seen at the hospital before or whether you must register him for the 1st time?

A

MPI (master patient index)

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11
Q

Each person who has the ability to access a computer software system, for instance EHR clinics, is set up within the software and assigned to an _ which is typically based on the person’s name

A

User ID

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12
Q

Which of the following is not a type of medical insurance

A

Self - pay from patient

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13
Q

Emails or faxes that are sent and arrive at the wrong location constitute a privacy __

A

Breach

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14
Q

Which of the following is a benefit of CPOE?

A

Clinical decision support is possible through CPOE

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15
Q

The health care professional types reports for care providers is known as an__

A

Transcriptionist

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16
Q

Summit Bay health center has partnered with 5 area physician’s office as well as a rehabilitation facility nearby for the purpose of offering high quality coordinated care to patients in that geographic area. This partnership is known as an__

A

Acountable care organization

17
Q

Doctor Glover’s office has one vendor for their practice management software and another for their electronic health record, but the systems are able to communicate with 1 another without duplicating data entry the systems are able to__

A

Interface

18
Q

Daniel Allen has been a patient at summit Bay health center for the following alignments: January 8th 2014 impatient for appendicitis, April 16th 2016 emergency department for asthma atrack, May 12th 2016 urgent care for visit illness, may 13, 2018 in patient for pneumonia and June 4th 2019 emergency department to sprained arm How many times will Daniel Allen’s name and demographic info be entered in the MPI of SBHC?

A

One

19
Q

Of the following, which is not part of the patient’s past medical or surgical history?

A

Marital status

20
Q

Every form should include the__so that the form’s use is obvious

A

Form name

21
Q

In a hospital, what piece of data is included in the MPI that allows a hospital to locate the corresponding health medical record for each patient?

A

Medical health record number

22
Q

Emily haver documented on her past history form that she had an arthroscopy of the right knee in 2018. On her next visit, the care provider was reviewing her past surgical history and mentioned that she had right knee arthroscopy. The patient realized she had written the wrong side and confirmed that it was her left knee which underwent arthroscopy what action would the provider take in this case?

A

Amend the record to show the correct information according to office policy

23
Q

Kat Simmons is a nurse at memorial hospital. She has just entered the soap note on her patient Alex Phillips by typing the sentences “the patient is resting comfortably he notes that his pain is a 7 on a scale of 1 to 10 he voices no other complaints” this is an example of_

A

Unstructured

24
Q

The ROS is documented for patient care purposes and also factors into the_

A

Care plan and charges

25
Q

The MPI and patient list should be kept__

A

Permanently

26
Q

In a hospital setting, what document is the equivalent of the assessment and plan that is collected as part of a soap note in an outpatient record?

A

Discharge summary

27
Q

Natalie Burns has just arrived for her 1 PM appointment with Dr.Earl she informs the healthcare professional that she is there for a follow up of her hypertension this is known as natalie’s__

A

Chief complaint