Chapter 12
Which of the following functions of the EHR program will be most helpful to the administration when reviewing the financial health of the practice?
Report generator
Which feature of an EHR program is used to produce revenue reports, aging reports, and office accounts receivable?
Report generators
Identify the advantages of ancillary programs for labs, X-rays, and other diagnostic services.
Results can be immediately uploaded to the patient's medical record. Results are transmitted back as soon as available.
HIPAA requires all patient information on the computer system to be held in strict confidentiality. Which of the following is an appropriate way to keep patient information secure?
Use screen savers to prevent patients from seeing more than they should. Use some type of software that tracks use by all users. Program the computer to log off after a short period of inactivity.
If the patient is not available to sign a release of information, what may you do to release medical records?
Wait until the patient is available to sign a release of information form
Mr. Abrams decided he did not want the practice to release his information to another medical facility. What must he do?
Withdraw permission in writing
All users of an EHR program must have individual
access codes. passwords.
Careful key entry and regular backup of electronic files help ensure ______ in electronic patient information.
accuracy
Many EHR programs use the term ______ for a correction made to an electronic health record.
addendum
When an error or omission is found in an electronic record, a(n) _______ is made as soon as possible.
addendum
Generally, once an entry in an electronic health record is saved, a correction is made by __________.
adding an addendum
In order to find out which patients are not paying their office claims and statements promptly, you could ask the EHR report generator to create a(n) __________ report.
aging
In order to find patient demographic information, you could ask the EHR report generator to create any of the following reports, except.
aging
An individual's lifelong health record is a(n):
PHR
Which type of electronic record is owned and maintained by the patient?
PHR
Identify the characteristics of a PHR.
PHRs contain treatment information from multiple providers. PHR files are owned and updated by the individual.
Which of the following is a true statement about a patient's personal health record (PHR)?
PHRs may be stored and maintained on secure Internet sites.
Which of the following types of reports can be produced using the report generator in an EHR program?
Patient aging reports Patient statistics Accounts receivable
Which of the following is not an advantage of the integration of ancillary programs for labs and other diagnostic and therapeutic services with an EHR system?
Patients do not have to wait as long for lab or diagnostic appointments.
Part of meaningful use is to empower patients and families. How is that to happen?
Patients should be given reading material and providers should make sure patients understand all of their options
What type of patients are more likely to adhere to agreed-upon care plans?
Patients who understand the rationale behind their care Patients who are engaged partners Patients who feel that their care providers listen to them
Identify the tasks that a patient can do using a patient portal.
Paying a balance on an account Accessing a child's immunization record Scheduling an appointment
Which items may be needed to create a new patient record in an EHR program?
Physician notes Laboratory orders Patient information form
Which of the following must be taken into consideration when creating an appointment matrix in an electronic scheduling system?
Physician's meeting schedule Hours when patients are not seen Physician's vacations
Which of the following are potential deterrents for implementing electronic health records?
Possible damage to the system Maintenance costs Staff training requirements
Which of the following allows the entry of prescriptions, which can be transmitted directly to the pharmacy or printed and given to the patient?
Prescription writers
Angie is a new patient at Dr. Vander's office. She has an ear infection and the practitioner is prescribing an antibiotic. The medical office uses an EHR system and wants to transmit her prescription directly to Angie's pharmacy. She filled out the standard patient information sheet, but unfortunately, she cannot remember the name or phone number of her pharmacy. What should Dr. Vander's office do?
Print the prescription from the EHR software.
Identify the additional advantages of a fully functioning EHR program.
Providers in different locations can look at the same record at the same time. Physicians can access records from any computer with a secure access code.
EMR
Record of health-related information for a single patient that is created and maintained by a single healthcare organization
Which of the following are ways to ensure the accuracy of patient information in an electronic health record?
Regular backup of electronic files Careful key entry
In addition to the recipient and patient information, what other information should be on the release of information form?
The reason for the request
In which ways can computerized records also be useful as tickler files?
They can alert staff about patients who are due for yearly checkups. They can alert staff to patients who require follow-up care.
Identify the advantages of electronic schedulers.
They can easily look up a patient's appointment. They can keep a list of patients who want an earlier appointment. They allow multiple users at a time.
In an EHR, the abbreviation "RX" means which of the following?
Treatment Prescription Therapy
Practitioners can engage patients in medical decision-making by sharing what kinds of information with them?
Treatment options Risk factors Illness information
In an effort to safeguard patient records, medical office employees should:
only be given access to records they need to perform their duties.
Once a signed release is obtained, you may copy and release
only those items of the record covered by the release of information.
A patient's personal health record is owned by the __________.
patient
Who enters the data into a personal health record (PHR)?
patient
Which of the following is not likely to be a required field in your EHR software's form to be completed for each new patient?
patient driver's license
A ______ allows a patient to access routine information and perform tasks such as making appointments online.
patient portal
An electronic version of the comprehensive medical history of a patient's lifelong health that is kept by the individual patient is called a(n)
personal health record.
Communication problems that contribute to medical errors in a medical facility include all of the following except __________.
poor telephone etiquette
Many offices and EHR systems today allow patients to access and interact with certain parts of their EHR by providing a patient __________ to the system.
portal
If an EHR's coding software detects a charge that does not match a diagnosis code, it may __________.
produce a flag to alert the medical office
The greatest concern of electronic health records is __________.
protecting the confidentiality of patient records
Information in a new patient template, such as name, address, and insurance information, appears in ______ fields.
required
Information that is mandatory in an EMR or EHR is denoted in the record by
required fields.
Which of the following is mandated in Stage 2 of "meaningful use" of EHRs for Medicare or Medicaid patients?
sending and receiving clinical information electronically
Common abbreviations are often used in the electronic health records. What does the abbreviation SX stand for?
symptoms
Files that need periodic attention are called ______ files.
tickler
How is security maintained if providers access EHR programs from home or other locations?
Access codes and passwords are used
What percentage of the U.S. gross national product is accounted for by healthcare costs?
17.8%
The goal of George W. Bush's executive order was that most Americans would have access to electronic health records by ______.
2014
The goal of the presidential executive order signed in August 2006 was to give most Americans access to electronic health records by the year __________.
2014
An EMR is created, compiled, and managed by whom?
A single healthcare organization
Which item below maintains each user's ability to work in certain areas of a patient's electronic health record?
Access code
Which governmental mandate resulted in EHR and meaningful use?
Affordable Care Act
Customized
An EHR software program changed to suit a specific specialty and style of a physician's office
Which of the following are benefits of having individual access codes and passwords in an EHR program?
An access code allows each user to access only designated areas of a record. An access code inserts a date and time stamp in the record to track who has accessed it.
What is the most appropriate action when an error or omission is found in an electronic record?
An addendum is made as soon as possible
Which function of an EHR allows for electronic test ordering and receipt of results?
Ancillary order integration
When should a mistake be corrected?
As soon as the mistake is discovered
What is the ultimate goal of EHR implementation and meaningful use?
Better patient care
To have better clinical outcomes, documentation should be which of the following?
Clear Complete Concise
Electronic claims submission and coding of medical record is done through which component of an EHR?
Coding software
You have received a request for a patient's medical records from a lawyer; the patient's cousin comes to the office to sign a release for the patient because that patient is critically injured and in the ICU. The cousin says he is the next of kin but is not listed in your records as the patient's next of kin. He also has a court document listing him as guardian for this patient. What should you do?
Copy the POA and let the cousin sign the release of information.
What is the primary reason most providers give for not implementing EHRs in their offices?
Cost
Identify the goals of promoting electronic health records.
Create record uniformity Decrease medical errors
Under the HIPAA privacy and security act, a medical office should maintain documentation of which of the following?
Date when information was released Requests for patient information Patient permission for release of information
Like the rest of the office staff, Barry is still learning how to use the new EHR system installed in the medical office. He is with a patient and is attempting to document the patient's chief complaint in the EHR system, but he cannot get the system to accept the information. What should Barry do?
Document the patient's chief complaint on paper and enter it later into the EHR system.
Patient electronic health information created in a format meeting interoperability standards is defined as being in a(n) _______ format.
EHR
Identify the characteristics of an EHR.
EHR files are owned and managed by providers or facilities. EHR access is controlled by the provider with patient authorization.
An electronic record of health-related information that can be utilized by members of more than one healthcare organization is known as a(n)
EHR.
An electronic record of health-related information for an individual patient that is created, compiled, and managed by providers and staff within a single healthcare organization is called a(n)
EMR.
Identify the advantages of electronic health records.
Ease of chart access for multiple users Fewer lost records Increased legibility of charts
Which of the following are advantages of electronic health records?
Efficiency in records transfers Reduced storage needs Increased access to educational materials
Which of the following are advantages to billing and coding software within EHR programs.
Electronic claims can be submitted directly to insurance carriers. Alerts can produce flags notifying users of errors. Procedure and diagnostic codes can be automatically assigned.
Electronic medical record
Electronic record of health-related information for an individual patient that is created, compiled, and managed by providers and staff members in a single healthcare organization
Electronic health record
Electronic record of health-related information for an individual patient that is created, managed, and gathered in a manner that conforms to nationally recognized interoperability standards
Which of the following materials are needed to schedule an appointment using an electronic scheduler?
Electronic scheduler Template outlining time frames for appointment types
PHR
Electronic version of a patient's complete medical history that is created and maintained by the individual patient
Personal health record
Electronic version of the complete medical history and record of a patient's lifelong health that is collected and maintained by the individual patient
Place the steps in scheduling a patient appointment with an electronic scheduler in order, with the first step on top.
Establish the type of appointment required by the patient, noting if it is for a new patient or an established patient. Consult the office template for the amount of time required for the patient appointment. Ask if the patient has a preferred time frame, and try to schedule appointments earlier in the day first. Use the search option to find the next available appointment for the time frame required by the patient. Once the patient agrees to the appointment time, enter the patient's name, phone number, and reason for the appointment.
What laws dictate that PHI cannot be disclosed without the patient's express written permission unless allowed by federal or state statute?
HIPAA
The need to maintain a list of releases of patient information is mandated by
HIPAA.
EHR
Health record created in electronic format that can be shared among multiple providers
Which of the following is a disadvantage of using an electronic scheduler?
If the computer is down, the day's schedule is not accessible.
What is the number one patient related issue to (hopefully) be decreased by the use of EHR programs?
Illegible handwriting
Which of the following are objectives of Meaningful Use?
Improve care coordination Reduce health disparities Better clinical outcomes Engage patients and family
Which of the following is not one of the expected outcomes of EHR interoperability mandates?
Increased responsibilities for medical assistants
A template for a new patient record would most likely include which of the following required fields?
Insurance information Name Address
Which of the functions of the EHR program would be most helpful to the staff who schedules appointments for patients with specialists?
Insurance verification
Which of the following is an advantage of an electronic scheduler?
It allows multiple users at any time.
Which of the following apply to PHI?
It stands for protected health information. The patient's express written permission is required for non-federal or state disclosures. It is protected by HIPAA laws
Which of the following are general guidelines for using EHR programs?
Keep password information secure Retrieve patient records carefully Secure the computer that maintains the EHR Be familiar with the software and hardware
Which of the following is an advantage of EHRs?
Legibility of records
Identify the functions of an electronic prescription writer.
Maintain a list of commonly prescribed medications and dosages Flag an ordered prescription as a potential allergy interaction Transmit prescriptions directly to the pharmacy
___________ improves the quality, safety, and efficiency of certified electronic health records.
Meaningful use
Which of the following phrases tells you that the record format is an electronic health record instead of an electronic medical record?
Meets interoperability standards
Which of the following are examples of communication problems that may lead to medical errors?
Mislabeled laboratory orders Mishandled patient messages
At the provider's request, Tony is attempting to enter a prescription for Mrs. Johnson for her high blood pressure. The EHR system keeps reporting an error: Incompatible medication. What might this mean, and what should Tony do about it?
Mrs. Johnson is either allergic to the medication or is taking another medication that interacts with it; Tony should consult the healthcare provider.
Which organization has defined the terms electronic medical record and electronic health record?
NAHIT
Which of the following can be tracked by an EHR program?
Number of visits allowed by a referral Time frame involved with a referral Number of visits remaining on a referral
Mr. Abrams is going to a specialist regarding an injury to his hand. He completes a release of information to have his records sent to the specialist. What information should be sent?
Only the information covered by the release form Correct
Place the following steps in creating a new patient record with EHR software in order, with the first step on top.
Open the New Patient window of the EHR program. Enter the patient's full name. Carefully inspect all information entered for accuracy. Save the new patient information.
Place the steps for creating an appointment matrix using an electronic scheduling system in order, with the first step on top.
Open the office appointment scheduler. Block the dates and times when the office or physician will not be available for patient appointments. Enter a reason that the time is not available for future reference. Specify time frames necessary for different types if appointments.
Which of the following will not reassure patients about the privacy and security of the office EHR system?
Sharing "computer frustrations" with the patient.
Which of the following is not an acceptable method of reassuring patients and other staff members about EHR confidentiality and security?
Show patients that anyone can view their medical information.
In which of the following ways can a medical assistant help reassure patients that the office EHR program and the information it contains are confidential and secure?
Show patients their own medical records and how information is entered and maintained. Be knowledgeable about the confidentiality and security aspects of the program.
Which of the following possible features of an EHR/practice management system will likely require customization?
Specialty office
Which stage of "meaningful use" of EHRs for Medicare and Medicaid patients includes documenting the percentage of visits, diagnoses, prescriptions, immunizations, and other pertinent health information electronically?
Stage 1
Which of the following lists the total amount of the charges, the amount paid by the insurance plan, deductibles, and the copayment or coinsurance balance due from the patient?
Statement
Which of the following are strategies for focusing on the patient, not the computer, during a patient encounter.
Take notes and enter them in the computer later Be comfortable with the system being used
Jose Gutierrez, now 18 years old, has been a patient of your practice since he was a small child. His mother has always been included when any information is given to Jose. His mother called the office to obtain the latest lab results from Jose's last doctor's appointment. What should you do?
Tell her that Jose must sign a release in order for you to give her information.
Which of the following are characteristics of a customized EHR software program?
Templates allow the physician to add entire phrases with a few clicks of the mouse. Terms such as congestive heart failure may be quickly selected in a cardiologist's office.
How often should passwords be changed in the EHR system?
as directed by the healthcare facility policies
How many identifiers are required to correctly identify a patient's EHR?
at least 2
Although the medical record itself is the property of the medical practice, the information in the record
belongs to the patient and must be kept confidential.
Most programs include a patient ______ component so the administrative staff can produce a billing statement for the patient.
billing
Better __________ occur when medical record documentation is clear, concise, and complete.
clinical outcomes
Many of the medical errors that can lead to patient death can be traced to ______ problems.
communication
Explaining the office access process to patients, showing patients their own medical records, and maintaining a positive attitude about a new EHR program can help reassure patients that their information is
confidential. secure.
It is important that you follow HIPAA guidelines when releasing a patient's protected health information and do so without violating
confidentiality regulations.
An EHR software program may be ______ to suit a specific specialty and style of a physician's office.
customized
The access codes that allow users to enter patient records in an EHR system insert a(n) __________ in the medical record, so that office administration can tell who is accessing each medical record.
date and time stamp
Many EHR programs can verify a patient's insurance coverage and simultaneously capture the patient's __________.
demographic information
Dr. Hillman broke his leg while he was on vacation last week. His office has fully implemented EHR, so he plans to work from home part of the time. He will go into the office only as necessary to see patients. Which of the following is not possible for Dr. Hillman using the EHR system?
diagnose software problems on his home computer
Many EHR programs make insurance verification ______ by assisting with online verification.
easier
EHR software programs allow for ______ transmission of referrals among the PCP, specialist, and insurance plan involved.
electronic
Which function of EHR programs allows the staff to make appointments for patients?
electronic scheduler
When information such as the result of a laboratory test is entered into a patient's EHR, the information is available for viewing __________.
immediately
Which of the following was not a reason for development and promotion of electronic medical records?
increasing age of the general population
A personal health record (PHR) is maintained by the
individual patient.
Medical errors are somewhere between the 3rd and 8th leading cause of death for hospitalized patients. Most of these errors can be traced to all of the following communication problems except __________.
information that is written in blue ink in a paper medical record
An electronic health record must contain information that is created, managed, and gathered in a manner that conforms to ______ standards.
interoperability
In this morning's monthly financial status meeting, the office manager asked Cheryl for an analysis of how much revenue is generated by each of several procedures that are commonly performed in the medical office. To accomplish this in the most accurate and efficient manner, Cheryl should ____.
use the EHR software's report generator
Computer storage of files is a good option when:
you have a limited amount of space.
