Chapter 5 EHR

"Patient complains of urinary frequency." This would be considered:

CC

The reason for the patient to seek care from the provider is called:

CC

Allergies can be classified as all of the following except:

Chronic

"The dizziness is on and off during the day." This information would be considered:

Chronology

Which of the following is not a guideline for e-visits?

E-visits may be offered to new and established patients.

Genetic disease risk would be covered under which part of history?

Family

"Blood pressure is 120/80 mm/hg." This information would be considered:

a plan

"MRI of the brain" is an example of:

a plan

"Patient complains of dizziness." This is considered:

a symptom

"Condition presents suddenly and is usually severe but of brief duration." This would be considered a/an:

acute condition

Weight and height are considered:

anthropometric measurements

"Diagnosis is type 1 diabetes." This information would be considered:

assessment

Congestive heart failure and asthma are examples of:

chronic conditions

"Patient has URI over the past 5 days." This information would be considered:

duration

An evaluation and management service provided by a provider or other qualified health professional to an established patient using a Web-based or similar electronic-based communication network for a single patient encounter that occurs over safe, secure, online communication systems is known as a/an:

e-visit. Web visit. online consultation. All of the above +++++

An allergy to latex would be classified under:

environmental

Documentation:

makes diagnosis and treatment more efficient and effective. promotes patient safety. serves as a risk management function. All of the above ++++

Documentation for an immunization would include:

name of immunization. date given. location of injection. All of the above ++

In the S.O.A.P acronym for progress notes, the "O" stands for:

objective

Vital signs, anthropometric data, imaging studies, and laboratory tests are examples of ________ information.

objective

What is often referred to as the "Fifth vital sign"?

pain scale

Which of the following is NOT an example of when telephone documentation should be utilized?

patient referrals

Smoking status of the patient would be discussed under which history type?

social

A technology that converts speech into text as the provider speaks into a microphone is:

speech recognition software

Data documentation in the patient's own words about why he or she presents to the office is:

subjective