Chapter 9 Quiz Questions CMAA

HPI

A chronological description of the development of the patient's present illness from the first sign or symptom or from the previous encounter to the present

CC

A patients statement about the reason for his or her encounter

How will the medical office keep track of this new patient's medical record? a. The EHR will extract the patient's social security number for use as a medical record number. b. Nancy Estrada will assign a number to the patient's medical record. c. The EHR will automatically create a unique medical record number for the patient. d. Nancy Estrada will use the patient's birthdate as his medical record number.

c. The EHR will automatically create a unique medical record number for the patient.

Select the correct statement regarding signatures on medical records. a. The physician's initials may be used for progress notes. b. Test results do not need the physician's signature or initials. c. The treating or attending physician must sign each progress note. d. An initial log used to identify signatures is not acceptable on medical documents. e. Initials can never be used instead of an original signature.

c. The treating or attending physician must sign each progress note.

A flow sheet: a. is no longer allowed according to HIPAA b. is one of the three basic medical record organizational systems c. can be used to help view continuous problems and comparative values d. can be used instead of dictating such things as lab results, blood pressure, and immunizations e. takes the place of listing data in the medical record

c. can be used to help view continuous problems and comparative values

When an error in a paper-based medical record is discovered, the first step is to: a. draw a heavy line through the incorrect entry b. erase the incorrect entry c. draw a single line through the incorrect entry d. use correction tape to obliterate the incorrect entry e. use white correction fluid to obscure the incorrect entry

c. draw a single line through the incorrect entry

The patient in the video is a new patient who has not yet been seen by this medical office. This means that the: a. patient must ask his former physician to send over his medical records before the new physician will see him. b. patient must give his medical record from his former physician to the medical assistant upon check in. c. medical assistant must create a new medical record for this patient before he is seen by the physician. d. medical assistant will create a new medical record for this patient following his encounter with the physician.

c. medical assistant must create a new medical record for this patient before he is seen by the physician.

A type of internal review where medical staff look at medical records to verify that good recordkeeping is in place and that documentation is valid before billing is submitted is called a/an: a. external audit b. self-audit c. prospective review d. retrospective review e. external review

c. prospective review

A type of internal review where medical staff look at medical records to verify that good recordkeeping is in place and that documentation is valid before billing is submitted is called a/an: a. external review b. retrospective review c. prospective review d. self-audit e. external audit

c. prospective review

Because the patient in the video is new to the medical office, to create the patient's medical record the medical assistant, Nancy Estrada: a. scans the patient information form and attaches it to the EHR. b. types a label with the patient's name and adds it to a file folder. c. types information from the patient information form into the EHR. d. asks the patient a series of questions and types his responses into the EHR.

c. types information from the patient information form into the EHR.

Select the correct definition for "meaningful use." a. Providers "mean to" and treat patients according to quality of care standards. b. Medical offices follow "meaningful use" rules for security of their computer systems. c. Physicians "use" medical recordkeeping technology in a "meaningful" way. d. EHR technology is used in a meaningful manner. e. Practice management organizations mandate "meaningful use" rules for office security.

d. EHR technology is used in a meaningful manner.

Which medical record organization system arranges documents in chronological order? a. Source-Oriented b. Flow Sheet c. Problem-Oriented d. Integrated

d. Integrated

A HIM professional: a. is a security officer who oversees the security of EHR systems b. is a privacy officer who oversees the privacy of EHRs c. is an expert on EHR software d. collects, integrates, analyzes, and codes health care data e. both a and b

d. collects, integrates, analyzes, and codes health care data

Medicare documentation guidelines state that: a. the 1997 guidelines replace the 1995 guidelines b. outpatient physicians should use the newer 1997 guidelines c. outpatient physicians should use the 1995 guidelines d. outpatient physicians can use either the 1995 or the 1997 guidelines e. both a and b

d. outpatient physicians can use either the 1995 or the 1997 guidelines

During a comprehensive physical examination, the physician examines: a. the body starting in the core (chest and stomach) first, then works toward the extremities and head b. the body starting at the feet and working toward the head c. the body area mentioned in the chief complaint first d. the body starting at the head and working toward the feet e. all areas that do not look normal first

d. the body starting at the head and working toward the feet

ROS

An inventory of body systems that begins with the head

PH

Information about a pt's previous illnesses, treatments, medications and so on

The term _______ means that electronic health record technology be used in a meaningful manner to support efficient, quality, and coordinated patient care.A Stage 2 Core-Set Objective is to generate and transmit electronic ___________ .Another Stage 2 Core-Set Objective is to provide patients with ____________ summaries following each office visit. _______ includes the patient's health history, symptoms, treatment history, lifestyle choices, ongoing biometric data, or other health-related data created, recorded, and gathered to assist the patient with their health concerns.

The term meaningful use means that electronic health record technology be used in a meaningful manner to support efficient, quality, and coordinated patient care.A Stage 2 Core-Set Objective is to generate and transmit electronic data .Another Stage 2 Core-Set Objective is to provide patients with clinical summaries following each office visit. Patient Generated Health Data includes the patient's health history, symptoms, treatment history, lifestyle choices, ongoing biometric data, or other health-related data created, recorded, and gathered to assist the patient with their health concerns.

SH

a review of the patients past and current activities, occupations and habits

The medical office in this video is working on meeting the meaningful use objectives and has successfully met the objectives for Stage 2. How will the patient in the video directly benefit from this accomplishment? a. He will leave the medical office with a clinical summary of his encounter. b. The information he provided about his smoking status will be sent to a state registry. c. He will be able to view the health status of other patients with similar conditions. d. He will now be able to make changes to his medical record.

a. He will leave the medical office with a clinical summary of his encounter.

When converting from a paper-based medical record system to an electronic system some practices maintain portions of the record on paper, which are referred to as: a. hybrid records b. transitional records c. e-paper records d. temporary records e. e-docs

a. hybrid records

An example of subjective information would be a/an: a. patient's expression of the pain level b. laboratory test c. temperature d. blood pressure reading e. EKG reading

a. patient's expression of the pain level

One advantage of a paper-based medical record system is: a. people feel secure with a piece of hard copy information in hand b. they are less vulnerable to security threats c. they are easy to move d. management costs are reasonable e. they are easy to store

a. people feel secure with a piece of hard copy information in hand

A medical assistant will typically document all of the following items in a patient's medical record except: a. physical examination findings. b. the patient's name and the current date. c. immunizations the patient receives. d. the patient's chief complaint for the encounter.

a. physical examination findings.

The difference between an electronic signature and a digital signature is that: a. the digital signature is a series of letters or numbers that cannot be altered, and an electronic signature is a facsimile of a person's actual handwriting b. the digital signature is secure and cannot be forged, and the electronic signature uses an encryption system to make it secure c. the electronic signature is affixed electronically to the end of the document, and the digital signature is a facsimile of a person's actual handwriting d. the electronic system uses such things as a voice print, handprint, or finger print and the digital system uses a biometric system e. the digital signature is a facsimile of a person's actual handwriting, and an electronic signature is a series of letters or numbers that cannot be altered

a. the digital signature is a series of letters or numbers that cannot be altered, and an electronic signature is a facsimile of a person's actual handwriting

A medical record is the property of: a. those who create it b. the patient c. the person named the Durable Power of Attorney for Health Care d. the local hospital e. both a and b

a. those who create it

Which of the following statements about signatures is correct? a. A medical assistant may not sign a physician's name to a document the physician has dictated. b. Digital signatures are more secure than electronic signatures. c. An electronic signature uses identification encryption for authentication. d. Digital signatures may be altered by someone with access privileges

b. Digital signatures are more secure than electronic signatures.

One of the forms the patient in the video is asked to sign is related to HIPAA Notification. What is the purpose of this form? a. It acknowledges that the patient has read and understands the medical practice's compliance plan. b. It allows the practice to use and disclosure of protected health information for specific purposes. c. It allows the patient to make changes to his medical record as needed. d. It requires the practice to seek the patient's permission prior to releasing protected health information.

b. It allows the practice to use and disclosure of protected health information for specific purposes.

Documents are arranged according to sections in the: a. integrated record system b. SOR system c. POMR system d. flow sheet e. SOAP format

b. SOR system

The complexity of medical decision making is dependent on which three items? a. The (1) review of systems, (2) body areas examined, and (3) organ systems examined. b. The (1) number of diagnoses and management options, (2) amount and complexity of data to be reviewed, and (3) risk of complications, morbidity, and comorbidities or mortality. c. The level of (1) history, (2) physical examination, and (3) number of diagnoses. d. The (1) diagnoses, (2) treatment, and (3) prognosis e. The level of (1) personal, (2) family, and (3) social history.

b. The (1) number of diagnoses and management options, (2) amount and complexity of data to be reviewed, and (3) risk of complications, morbidity, and comorbidities or mortality.

A ROS is: a. a presenting complaint expressed by the patient b. an inventory of each body system c. the history of the patient's family medical events d. an examination of each body system e. a personal history of the patient, including childhood diseases, all previous illnesses, and so forth

b. an inventory of each body system

Documenters of the medical record: a. should be only physicians in the medical practice b. are all individuals who provide health care services c. need to be licensed health care providers d. have to be the attending or ordering physician e. all of the above

b. are all individuals who provide health care services

Documenters of the medical record: a. should be only physicians in the medical practice b. are all individuals who provide health care services c. need to be licensed health care providers d. have to be the attending or ordering physician e. all of the above are correct

b. are all individuals who provide health care services

Time passes, and the patient in the video has been established patient for over a year. During one appointment he asks for a copy of his medical record. In this situation, Nancy Estrada should: a. ask the office manager if granting the patient access is permissible. b. follow the office procedure for granting patients access to their medical records. c. politely explain that the medical record is the property of the medical office. d. allow the patient to sit at her computer workstation to review his medical record.

b. follow the office procedure for granting patients access to their medical records.

Which statement best describes an electronic recordkeeping system as compared to a paper recordkeeping system? a. more costly to manage b. less time consuming to maintain c. more vulnerable to tampering d. less efficient to use

b. less time consuming to maintain

Select the sentence that best describes an EHR practice management system. a. A digital version of patients' paper charts. b. An EMR system that shares electronic information within the practice setting. c. An interoperable system that shares data outside the medical practice. d. A database that is accessible electronically. e. Both a and b

c. An interoperable system that shares data outside the medical practice.

Select the phrase that is true regarding documentation using an EMR. a. Templates are not to be used to document in an EMR. b. "Smart phrases" are not to be used to document in an EMR. c. Both templates and "smart phrases" may be used to document in an EMR. d. Cloning is allowed under certain circumstances when documenting in an EMR. e. Both a and b

c. Both templates and "smart phrases" may be used to document in an EMR.

The acronym "SOAP" stands for: a. Subjective, Objective, Appraisal, Program b. Subjective, Operative, Action, Plan c. Subjective, Objective, Assessment, Plan d. Secure, Object, Aim, Purpose e. Sensible, Operational, Analogy, Plan

c. Subjective, Objective, Assessment, Plan

The difference between an electronic signature and a digital signature is: a. the electronic signature is affixed electronically to the end of the document, and the digital signature is a facsimile of a person's actual handwriting b. the digital signature is secure and cannot be forged, and the electronic signature uses an encryption system to make it secure c. the electronic system uses such things as a voice print, handprint, or fingerprint, and the digital system uses a biometric system d. the digital signature is a series of letters or numbers that cannot be altered, and an electronic signature is a facsimile of a person's actual handwriting e. the digital signature is a facsimile of a person's actual handwriting, and an electronic signature is a series of letters or numbers that cannot be altered

d. the digital signature is a series of letters or numbers that cannot be altered, and an electronic signature is a facsimile of a person's actual handwriting

The provider who renders service to the patient in an office setting is referred to as the: a. consulting physician b. attending physician c. referring physician d. treating physician e. ordering physician

d. treating physician

The provider who renders service to the patient in an office setting is referred to as the: a. consulting physician b. referring physician c. attending physician d. treating physician e. ordering physician

d. treating physician

Select the correct statement(s) regarding documentation terminology. a. The acronym WNL should not be used when referring to an affected body area. b. The term negative should not be used without adding details to the documentation. c. Standard abbreviations, acronyms, and symbols may be used in documentation. d. The Joint Commission states, "any reasonable approach to standardizing abbreviations, acronyms, and symbols is acceptable." e. All of the above are correct

e. All of the above are correct

Which of the following has/have established laws to provide patients access to their medical records? a. HIPAA b. Privacy Act c. Centers for Medicare and Medicaid Services d. HITECH e. Both a and b

e. Both a and b

The HPI is: a. the patient's family history: all illnesses, diseases, and a list of deceased relatives b. the patient's social history including smoking, alcohol consumption, and sexual practices c. the chief complaint; reason for the visit d. a review of all body systems from top to bottom e. a chronological description of the development of the patient's present illness

e. a chronological description of the development of the patient's present illness

In a patient medical record, data can be: a. hand-entered by the physician b. dictated by the physician c. keyed into the system by the physician d. entered by the medical assistant e. all of the above

e. all of the above

An electronic record system can capture: a. the time an entry was made b. when a record was accessed c. the person who looked at a record d. if a record was altered e. all of the above are correct

e. all of the above are correct

In an EMR, the health care provider can document clinical findings: a. in a free-text narrative by keying information directly into the computer b. by dictating a report and having it transcribed and electronically fed into the record c. by selecting "pick lists" to generate narratives d. by selecting templates to generate narratives e. all of the above are correct

e. all of the above are correct

The diagnosis is: a. an impression b. an assessment c. a final conclusion d. based on history, physical examination findings, and sometimes diagnostic tests e. all of the above are correct

e. all of the above are correct

The progress note: a. documents a patient's clinical status b. compares past to current conditions c. reviews particulars of the case and communicates findings d. details a treatment plan e. all of the above are correct

e. all of the above are correct

CPOE is an acronym for: a. computer-based practical examination b. computer-based official examination c. computerized physician order entry d. computerized practitioner order entry e. computerized provider order entry

e. computerized provider order entry

With an electronic medical record, a scribe: a. edits medical record data that have been entered by the physician b. transcribes the complete medical record c. takes the role of a clinician who helps the physician with documentation d. documents what the doctor says, while inserting related comments e. fills in blanks, completes phrases/sentences, or keys in dictated text that the physician narrates

e. fills in blanks, completes phrases/sentences, or keys in dictated text that the physician narrates