EHR WEEK 4 QUIZ

The AAAHC (2011) specifies that entries in a patient record made at the time of an examination or assessment include which of the following? Select one: a. Chief complaint b. Medication reconciliation c. SOAP notes d. Demographic data

a. Chief complaint

Which of the following components of an EHR product are the least customizable? Select one: a. Documentation of orders b. Documentation of treatment c. Documentation of procedures d. Documentation of results

a. Documentation of orders

Interoperability between LOINC terminology standard and an EHR assist in establishing what type of data exchange? Select one: a. Lab results b. Pharmacy alerts c. Surgical reports d. Appointment reminders

a. Lab results

The AAAHC specifies that entries in the EHR patient record at the time of assessment must include all of the following except: Select one: a. Signatures of involved healthcare professionals b. Chief complaint c. Clinical findings d. Discharge diagnosis

a. Signatures of involved healthcare professionals

Which of the following is the best definition of "chief complaint"? Select one: a. The patient's main reason for the office visit b. A review of the patient's problem list c. The provider's diagnosis of the patient's condition d. A compilation of data gathered from the physical exam

a. The patient's main reason for the office visit

A medical office would use a PMS to support which of the following functions? Select one: a. To schedule a procedure with a health care provider b. To transmit lab data to the EHR c. To send a prescription to a pharmacy electronically d. To create a treatment plan for a patient

a. To schedule a procedure with a health care provider

In order to create a graphic display, an EHR system requires which of the following? Select one: a. numerical data b. digital images c. unstructured data d. coded text

a. numerical data

A EHR feature that allows an authorized user to compare two or more drug lists is called medication _____. Select one: a. reconciliation b. comparison c. alert d. retrieval

a. reconciliation

One benefit of using an EHR is the availability of ______ which help the practitioner document an assessment at the point of care. Select one: a. templates b. problem lists c. graphics d. flow charts

a. templates

A health care provider is most likely to find which of the following in her daily task list within an EHR system? Select one: a. A prescription b. A patient appointment c. A treatment plan d. A referral

b. A patient appointment

Which of the following individuals within a medical office is least likely to act on an "open" order? Select one: a. A medical assistant b. A physician c. A nurse d. A scheduling assistant

b. A physician

Which of the following statements about current EHR systems is incorrect? Select one: a. EHR systems may create graphic displays from coded numerical data. b. EHR systems are capable of displaying and reading narrative text. c. EHR systems are capable of creating reminders from structured data. d. None of these statements are incorrect.

b. EHR systems are capable of displaying and reading narrative text.

Which of the following EHR features might help the parent or caregiver of a pediatric patient feel reassured that their child is developing normally? Select one: a. Immunization schedule b. Growth chart c. Point of care documentation d. Mental health assessment

b. Growth chart

At which point during the workflow of a patient examination are the treatment orders generated? Select one: a. After the encounter is closed b. Immediately following the decision on diagnosis c. During the clinical history review d. Right before the patient's vital signs are recorded

b. Immediately following the decision on diagnosis

A physician has created an order for a patient within an EHR system. What happens as the next step in this process? Select one: a. A medical assistant inputs a status report into the EHR. b. The physician electronically signs the order. c. The order goes to the daily task list of the appropriate staff member. d. The EHR lists the order as open and pending.

b. The physician electronically signs the order.

What is the purpose of the examination protocol that is typically followed by physicians, nurse practitioners, and other general health care providers? Select one: a. To determine which special tests are needed b. To determine underlying causes of the chief complaint c. To confirm the correctness of the clinical diagnosis d. All answers listed

b. To determine underlying causes of the chief complaint

Which of the following is the best way to improve the completeness of a procedure note within an EHR system? Select one: a. Use free text b. Use a template c. Use dictation d. Use multiple sources

b. Use a template

To create a growth chart for a six-year-old patient, the EHR would be most likely to pull data from which of the following locations within the EHR? Select one: a. Patient history template b. Vital signs template c. Problem list d. Medication allergies list

b. Vital signs template

Before a primary care doctor decides whether a patient needs an additional diagnostic test to rule out a condition, he or she needs information from the ______. Select one: a. EHR b. assessment c. content standards d. All answers listed

b. assessment

Which of the following health care providers typically begins a patient assessment with a referral diagnosis? Select one: a. Nurse practitioner b. General practitioner c. Obstetrician/gynecologist d. Physical therapist

d. Physical therapist

Per the ONC-ATCB Meaningful Use Criteria, an EHR system must be able to transmit all of the following clinical patient information to another provider except ________. Select one: a. the patient's medication allergy list b. digital images of the patient's x-rays c. a summary of the patient's record d. information regarding procedures

b. digital images of the patient's x-rays

When creating an order for a patient procedure within an EHR template, a health care provider needs to enter the _____. Select one: a. referral letter b. order details c. procedure notes d. results report

b. order details

During the typical workflow of a general examination visit, when are the patient's vital signs taken? Select one: a. During registration b. Following the physical exam c. After stating the reason for the visit d. Once results of lab work have returned

c. After stating the reason for the visit

Which of the following statements about an ambulatory EHR product is true? Select one: a. National content standards specify what data must be included in the treatment plans. b. Overall, most ambulatory health care providers include the same data content in their treatment plans. c. An EHR product must be flexible to enable a health care provider to define the specific data content it needs. d. None of the above statements are true.

c. An EHR product must be flexible to enable a health care provider to define the specific data content it needs.

Which of the following statement(s) is/are true regarding the requirements of the Joint Commission (2011)? Select one: a. The Joint Commission leaves the actual specification of the content required in an assessment to each accredited health care organization. b. The Joint Commission requires the organization to define in writing the data and information gathered during assessment and reassessment. c. Both A and B d. Neither A nor B

c. Both A and B

Which of the following items is least likely to appear on a treatment plan? Select one: a. Instructions for a low-sodium diet b. A prescription for Lipitor c. Demographic information d. A referral for a cardiology consult

c. Demographic information

Roger Hoode receives a clinical summary from his primary care provider at the conclusion of his office visit. What is this patient least likely to find contained in the summary? Select one: a. The results of diagnostic tests b. A list of his current medications c. Details about his co-payment amount d. The reason why he sought treatment

c. Details about his co-payment amount

Dr. Kimble is documenting a patient exam at the point of care using a template. Which of the following best describes the process for developing a treatment plan for the patient? Select one: a. The system develops a treatment plan for the patient as the exam note is created. b. Dr. Kimble must open a new treatment plan template once he has completed the assessment. c. Dr. Kimble creates a treatment plan as one of the items in the existing template. d. The system enables Dr. Kimble to dictate his treatment plan and links the file to the exam

c. Dr. Kimble creates a treatment plan as one of the items in the existing template.

Which of the following best describes when a treatment plan is generated? Select one: a. Prior to being seen by the provider b. At the beginning of a visit with a provider c. During and/or after a visit with the provider d. Only when a referral is made to a specialty provider

c. During and/or after a visit with the provider

Which of the following is the most efficient way of adding the results of diagnostic test to the EHR? Select one: a. Keyed data entry b. Document scanning c. Electronic feed from a test instrument d. Cross-referencing a paper document

c. Electronic feed from a test instrument

Typical workflow registration activities include each of the following except: Select one: a. Confirmation of the patient's insurance information b. Verification of the patient's address c. Notification of drugs that require refills d. Statement of general reason for the visit

c. Notification of drugs that require refills

While providing patient history details, the patient tells the nurse that she does not smoke. What would the nurse do with this information based on CCHIT criteria within an EHR system? Select one: a. Add a free-text note that the patient does not smoke b. The nurse would only need to record the data if the patient did smoke c. Specify an absence of smoking within the patient history d. Inactivate "smoking" from the patient history

c. Specify an absence of smoking within the patient history

Which of the following is true about the ONC-ATCB Meaningful Use certification criteria when compared to the CCHIT Ambulatory Care Certification Criteria? Select one: a. The CCHIT criteria specifies the need for medication reconciliation. b. Both require that clinical lab results are presented in a human readable format. c. The ONC-ATCB criteria requires more specific information on smoking status. d. All answers listed are true.

c. The ONC-ATCB criteria requires more specific information on smoking status

A patient is sent by his primary care physician to a cardiologist. How does the cardiologist, who is using a certified EHR, initially learn about this patient's condition? Select one: a. The patient hands the cardiologist the physician's referral letter which explains everything. b. The patient explains the results of all previous visits to his physician to the cardiologist's medical assistant. c. The cardiologist reviews the patient's continuity of care record for information. d. The cardiologist reviews the patient's problem list and selects a focus for treatment.

c. The cardiologist reviews the patient's continuity of care record for information.

To support the treatment plan, the EHR system must be capable of which of the following? Select one: a. Automatically transmitting the information to the third-party payer b. Capturing the details of similar treatment plans for comparison c. Transmitting orders specified in the treatment plan to the appropriate health care practitioner d. Accepting a direct feed of results reporting from clinical information systems

c. Transmitting orders specified in the treatment plan to the appropriate health care practitioner

The steps a health care provider intends to follow to address a patient's problem must be identified in which of the following? Select one: a. Diagnostic order b. Problem list c. Treatment plan d. Medication list

c. Treatment plan

Per the ONC-ATCB Meaningful Use Criteria, at minimum the EHR system must be able to provide all of the following patient-specific education resources except: Select one: a. information related to the patient's problem b. information about the medication the patient is taking c. information about how to contact other patients with the same condition d. information about interpreting the patient's lab results

c. information about how to contact other patients with the same condition

A physician will use a(n) ________ to document the outcomes of a therapy. Select one: a. order entry template b. results report c. treatment note d. care plan

c. treatment note

Which of the following is not an example of electronic data interchange (EDI)? Select one: a. direct faxing b. secure e-mail c. voice mail d. All answers listed are examples

c. voice mail

A health care provider who enters assessment data using a template in the EHR is also doing which of the following? Select one: a. Creating a visit note b. Documenting at the point of care c. Providing evidence of care d. All answers listed

d. All answers listed

A patient's primary care physician informs the patient that he needs to see a dermatologist. Which of the following information must "travel" from the primary care provider setting to the dermatology setting? Select one: a. A referral letter b. A continuity of care record c. A continuity of care document d. All answers listed

d. All answers listed

A well-designed EHR system will have which of the following abilities? Select one: a. Facilitates the review of the existing patient data b. Captures new patient data c. Facilitates the modification/updating of patient data by authorized health care practitioners d. All answers listed

d. All answers listed

Based on the ONC-ATCB Certification Criteria for Ambulatory EHRs, at minimum an EHR must be able to provide order entry for which of the following? Select one: a. Medications b. Laboratory tests c. Radiology d. All answers listed

d. All answers listed

ONC-ATCB Certification Criteria for ambulatory EHRs requires which of the following vital signs must be recorded by the EHR at minimum? Select one: a. Patient's height b. Patient's blood pressure c. Patient's weight d. All answers listed

d. All answers listed

One feature of a certified EHR is that it can generate patient reminders for follow-up care. To accomplish this, the system would need to pull data elements from which of the following? Select one: a. Problem list b. Medication list c. Medication allergy list d. All answers listed

d. All answers listed

Which of the following accreditation organization requires that the treatment plans and therapeutic services provided to the patient be documented in the ambulatory patient record? Select one: a. AAAHC b. NCQA c. The Joint Commission d. All answers listed

d. All answers listed

Which of the following individuals may be involved in the collaborative development of a patient's treatment plan? Select one: a. Patient b. Provider c. Patient's representative d. All answers listed

d. All answers listed

Which of the following questions should the treatment plan and treatment notes answer? Select one: a. What action steps will be taken to address the patient's problem(s) b. What service(s) were provided c. What procedure(s) were performed d. All answers listed

d. All answers listed

Which of the following statements about the Continuity of Care Record (CCR) is correct? Select one: a. It is intended to be transmitted directly between providers. b. It is a standard set of patient data. c. It facilitates direct communication of important patient information. d. All answers listed

d. All answers listed

Dr. Pollen has ordered a PET scan for her patient which will occur at an imaging center in another location. How will the report detailing the results of this diagnostic test be captured within an EHR system? Select one: a. Via an electronic feed from the imaging center to the practice's EHR system b. Via an e-mail attachment sent by the radiologist to the practice. c. Via a scan of the results report and a manual update of the EHR order d. None of the above

d. None of the above

Where within a SOAP-formatted treatment note in an EHR system would the physician document a patient's treatment? Select one: a. The "S" section b. The "O" section c. The "A" section d. The "P" section

d. The "P" section

When implemented by an EHR system, which of the following ONC-ATCB Meaningful Use Criteria most directly affects the patient? Select one: a. The ability of the EHR to incorporate lab test results b. The ability of the EHR to record, store, and retrieve medication orders c. The ability of the EHR to implement clinical decision support rules d. The ability of the EHR to create discharge instructions

d. The ability of the EHR to create discharge instructions

When would a health care practitioner use free-text within an EHR? Select one: a. When it is necessary for that information to trigger alerts b. When it is important for that text to be redisplayed in other areas of the record c. When the information is supplemental and needs to be searchable d. When it is important to present the patient's own words verbatim

d. When it is important to present the patient's own words verbatim