EHRRRRR

अब Quizwiz के साथ अपने होमवर्क और परीक्षाओं को एस करें!

Dr. Ingram saw 1457 patients in the first quarter of 2011. He kept an up-to-date problem list on 898 of them. On what percentage of patients did Dr. Ingram meet meaningful use of the EHR related to use of a problem list? a) 1.6 percent b) 16 percent c) 62 percent d) 6.2 percent

c) 62 percent

Emily Haver documented on her past history form that she had an arthroscopy of the right knee in 2005. On her next visit, the care provider was reviewing her past surgical history and mentioned that she had 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 will the care provider take in this case? a) Nothing, leave the documentation as is, since that is what the patient initially stated. b) Place a paper note in the patient's folder noting there is an error in the patient's electronic record. c) Amend the record to show the corrected information, according to office policy. d) Have the office manager take care of it.

c) Amend the record to show the corrected information, according to office policy. The original must be corrected in the electronic record. The original will remain retrievable, but the correct information will be visible as well.

The administrator of the Meaningful Use program is: a) HIPAA b) HITECH c) CMS d) HHS

c) CMS

Reporting cases of fraud and abuse must be made to the: a) National Practitioner Data Bank b) Physician Quality Reporting Initiative c) Healthcare Integrity and Protection Data Bank d) Center for Medicare and Medicaid Services

c) Healthcare Integrity and Protection Data Bank

PrimeSUITE's User Guide is accessed through the ____ feature. a) Query b) Information c) Help d) Lookup

c) Help The User Guide is accessed through the Help feature.

Many offices use an internal, secure environment to communicate important information to their employees. This is known as a/an? a) Internet b) World Wide Web c) Intranet d) voice mail system

c) Intranet

Charges begin to accrue once the ____. a) appointment is made b) patient checks in at the reception area c) MA or care provider interacts with patient d) claim has been filed

c) MA or care provider interacts with patient Even after patient check-in, insurance charges do not start accruing until the patient interacts with a medical assistant or the care provider to begin the encounter.

Of the following, which password is most secure? a) record b) record58 c) Record**58 d) Record58

c) Record**58

You are the office manager of Greensburg Medical Center. You have received a letter from one of your patients, Ida Healthway, asking to know the names of all employees and care providers who have accessed her EHR within the last year, since she believes someone has been spreading information about her in the community. You will provide Ms. Healthway with this information, which is known as: a) a patient list b) release logging c) accounting of information disclosures d) information exchange

c) accounting of information disclosures Accounting for disclosures is required by HITECH and must be given to the patient upon request.

Michelle has just come across state statistics regarding the average length of stay in acute, short term hospitals for appendectomy patients. She runs a report of patients having undergone an appendectomy in the past year at her hospital so she can compare her hospital's average length of stay to that of other hospitals in the state. What is Michelle doing? a) calculating variance b) summarizing c) benchmarking d) standardizing statistics

c) benchmarking

E-mails or faxes that are sent and arrive at the wrong location constitute a privacy _____________. a) code b) encryption c) breach d) access

c) breach

An employee at Memorial Medical Practice released the diagnosis of a patient to the patient's spouse without an authorization. This is known as a/an _________________________. a) accidental disclosure b) privacy disclosure c) breach of confidentiality d) disclaimer

c) breach of confidentiality

In order for any test, procedure, or medication to be administered to a patient, there must be a: a) SOAP note b) History and Physical exam c) care provider's order d) consent from the patient

c) care provider's order

Which of the following is a benefit of CPOE? a) the results of a test are instantly received b) the patient receives his/her test results at the same time as the provider c) clinical decision support is possible through CPOE d) using CPOE is less costly for the patient

c) clinical decision support is possible through CPOE Though the order is sent instantly, once the provider hits send, the results are not instantaneous; the patient does not receive the results until the office notifies him/her of the results; use of CPOE does not affect the patient monetarily in any way. CPOE does, however, flag for any drug-drug interactions, dosing inconsistencies, etc., when used for prescribing.

CPT, which is used to code procedures in an office, is an example of a/an _____________. a) password b) accounting of disclosures c) code set d) storage method

c) code set Coding systems such as ICD-9-CM, ICD-10-CM/PCS, CPT, and HCPCS are all code sets that are required by HIPAA to file claims.

Keeping health information to oneself is known as protecting: a) security b) privacy c) confidentiality d) secrecy

c) confidentiality

When correcting written documentation in a paper record, it is necessary to: a) black out the incorrect information b) use red ink to rewrite the incorrect information correctly c) cross out the incorrect information with one line, enter the correct information, date and initial the correction d) do nothing, since care may have already been given based on the incorrect information

c) cross out the incorrect information with one line, enter the correct information, date and initial the correction

Dr. Handley prefers to see the Facesheet of her patients in a particular order. Dr. Adams prefers to see his in another order. The software used in their office allows each provider to view screens in a different way. This is known as: a) consistency b) a data dictionary c) customization d) a template

c) customization

Danielle ran a report of congestive heart failure patients. The report includes the patients' medical record numbers, age, admission and discharge dates, and attending physician. What type of report is this? a) aggregate b) custom c) detail d) summary

c) detail

Patti Wolfe, a coding supervisor at the local hospital, is auditing the quality of ICD-10-CM coding. She may start by running a ____________ index to scan for obvious inaccuracies. a) procedure b) master patient c) disease d) provider

c) disease

Which of the following is a benefit of voice recognition? a) lower cost to implement b) from the beginning it is less time consuming for the care provider c) documents are made part of the patient's record in a timelier manner d) one hundred percent accuracy is attainable

c) documents are made part of the patient's record in a timelier manner

Every form should include the _______________ so that the form's use is obvious. a) patient's name b) provider's name c) form name d) patient's chart number

c) form name The name of the form should be related to its purpose, such as "Patient History" or "Physical Exam."

The field that focuses on capture, retrieval, storage, and use of health information is: a) medical assisting b) health informatics c) health information d) health literacy

c) health information

In a hospital setting, the care provider takes the patient's history, details the reason the patient is being admitted and performs a physical exam. The report of this information is known as the: a) initial progress note b) discharge summary c) history and physical d) SOAP note

c) history and physical In the hospital, care providers compile patient history, reason for admission, and results of a physical exam into a report commonly known as the history and physical (H&P).

Of the following, which is not a benefit of ePrescribing? a) the patient's demographic and insurance information is sent to the pharmacy from the office b) there is less chance of medication errors being made c) it is less expensive for the patient d) care providers and pharmacists are alerted to possible food/drug or drug/drug interactions

c) it is less expensive for the patient There is no effect, positive or negative, on the cost to the patient when ePrescribing is used

Which of the following statements is true about a personal health record (PHR)? a) it is a legal document b) it is maintained by the care provider c) it is maintained by the patient (or legal guardian) d) it must be maintained in paper form

c) it is maintained by the patient (or legal guardian)

Greenway Medical Center uses a priority ranking system for their internal e-mail. The fact that the holiday luncheon will be held on December 6, 2011 would be a __________ priority email. a) high b) Medium c) low d) critical

c) low

Of the following, which is not part of the patient's past medical or surgical history? a) allergies b) current medications c) marital status d) dates of previous surgery

c) marital status Marital status is a piece of social data.

A patient is entered into the Patient list: a) each time he is seen. b) after a procedure. c) once. d) twice.

c) once. A patient only needs to be entered into the Patient List one time.

Which of the following statements is true about a paper record? a) information is retrieved in a timelier manner b) written notes are more accurate c) paper records are often illegible d) the paper record system allows for more efficient, thorough patient care

c) paper records are often illegible

In a medical office, a standard report that would be run to show how much each patient owes is the: a) revenue analysis report b) provider revenue report c) patient balances report d) payment analysis report

c) patient balances report

The ____ is an example of clinical information that is collected through an EHR. a) research effects b) regulatory guidelines c) plan of care d) insurance policy

c) plan of care A patient's plan of care is one piece of clinical information collected through an EMR.

Emily Haver is being seen by Dr. Clark today for her annual physical exam. She has been a patient of his for many years. She is currently being treated for hypertension and type 2 diabetes mellitus. In the late 1990's she was treated on several occasions for poison ivy. She has been treated since 2003 with Zoloft for mild depression. Of the following, which will not appear on Emily Haver's problem list? a) hypertension b) diabetes c) poison ivy d) depression

c) poison ivy Since poison ivy is an acute condition, and from the documentation given she is no longer being treated nor does it affect her current care, the problem is no longer active nor current.

Meaningful Use guidelines require the keeping of an up-to-date: a) dictation system b) chart note c) problem list d) past medical history

c) problem list A current problem list must be maintained to meet Meaningful Use requirements.

Of the following, which is not an element of the history of present illness (HPI)? a) duration b) severity c) quantity d) quality

c) quantity A physical exam includes objective findings of the care provider while the HPI includes the signs or symptoms that a patient communicates to the provider, such as the duration, severity, and quality of pain.

The quality of a digital image is known as the: a) pixels b) character recognition c) resolution d) default value

c) resolution

Neil Rabinski was asked by the care provider if he has had any difficulty breathing, shortness of breath, or noticeable wheezing. This is part of the review of systems for the __________________ system. a) gastrointestinal b) head/eyes/ears/nose/throat c) respiratory d) cardiovascular

c) respiratory

James Philips has asked that certain personnel within the office be prohibited from seeing his health information. This record will be flagged how in PrimeSUITE? a) confidential b) private c) restricted access d) sensitive information

c) restricted access

If a computerized physician's order is sent to the local hospital for a blood test, and the physician's office has already been notified of the test findings, this order is: a) pending b) ordered c) returned d) scheduled

c) returned If an order has been placed (ordered) and the results have been sent back to the ordering physician, this is known as being returned.

Craig James is in the office of Dr. Hammer for his annual physical. Dr. Hammer asks Craig a series of questions such as "do you have frequent headaches," "do you have frequency of urination," and "do you have difficulty sleeping." These questions are part of the: a) physical exam b) patient medical history c) review of systems d) social history

c) review of systems Physicians "inventory" the various body systems to determine if there are any signs or symptoms which might point to particular medical conditions.

One factor that might contribute to slow acceptance of EHRs is: a) laziness b) fear of change c) security fears d) space concerns

c) security fears Some medical professionals are worried that an electronic system of record-keeping will not be secure, so they are hesitant to adopt EHR systems.

A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI). a) associated signs and symptoms b) modifying factors c) severity d) location

c) severity The fact that her pain is an 8 on a scale of 1 to 10 refers to the severity of the pain.

The presence of many conditions which pose a threat to public health must be submitted in accordance with applicable law. The ability to do so electronically would satisfy which menu objective? a) immunization registry b) patient education c) syndromatic surveillance d) summary of care

c) syndromatic surveillance

On October 18, an accident occurred on the local interstate highway. Fifteen patients were brought to the local hospital's emergency department with injuries ranging from minor to life-threatening. These 15 patients would be found in the ______________ registry. a) cancer b) death c) trauma d) implant

c) trauma

computer virus

can't program, so it on a computer floppy gift, hard drive, or CD, they can destroy or corrupt data

Of the following, which is not an application of an EHR system capture of insurance policy number

capture of insurance policy number

Entering data into a computer system is also known as ________________ data.

capturing

Screenshot: Entering data into a computer system is also known as ....?

capturing

Entering data into a computer system is also known as ________________ data.

capturing Saving information into computer software is known as data capture.

Entering data into a computer system is also known as capturing data

capturing data

Christine Simmons arrived for her appointment with Dr. Shumaker 20 minutes ago. The healthcare professional has just left the room after taking Christine's vital signs and medical history. What will be the next step in Christine's flow through the overall process? care provider

care provider

There must be a ____ to perform any tests or treatments.

care provider order

There must be a ________ to perform any tests or treatments.

care provider order

There must be a _________ to perform any tests or treatments.

care provider request.

In order for any test, procedure, or medication to be administered to a patient, there must be a:

care provider's order

A review of systems is documented for patient care purposes and also factors in the ________ for the patients visit?

careplans, charges, diagnosis, and assessments

An advantage of practice management software is review of the electronic claim for diagnosis and procedure code errors or inconsistencies. Catching any errors prior to the claim being sent to the insurance carrier improves _______________.

cash flow

At Heller Memorial Hospital, all patients, regardless of the type of patient, emergency department, inpatient, outpatient diagnostics, etc., are registered through the same department. This is known as:

centralized registration

The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient's visit.

charges

Posting patient charges occurs during which step(s) of the process in an office setting check-out desk

check-out desk

Natalie Burns has just arrived for her 1:00 p.m. 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 chief complaint

chief complaint

Natalie Burns has just arrived for her 1:00 p.m. 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:

chief complaint

The extent of a physical exam will depend largely on the reason for the patient's visit, which is otherwise known as what?

chief complaint

Memorial Hospital is in the process of researching a new facility-wide electronic health record system. The ___________________ would be responsible for assessing the budgeting process, funding, and for monitoring the monetary aspects of the project.

chief financial officer

Memorial Hospital is in the process of researching a new facility-wide electronic health record system. The chief financial officer would be responsible for assessing the budgeting process, funding, and for monitoring the monetary aspects of the project.

chief financial officer

chief financial officer. Part of the responsibility of the chief financial officer is to develop budgets and monitor spending.

Physicians practices sometimes use a service to check for errors on claim forms prior to submitting them. This is known as a......?

clearinghouse

Physicians' practices sometimes use a service to check for errors on claim forms prior to submitting a claim to the insurance company. The service that processes insurance claims is a/an: clearinghouse

clearinghouse

Which of the following is a benefit of CPOE?

clinical decision support is possible through CPOE

In a ___________ environment, the physician's office or hospital has the advantage of unlimited processing and storage capacity.

cloud

In many managed care plans, patients are responsible for paying a portion of the charges at the time services are rendered. This is known as the.....

co-pay

In many managed care plans, patients are responsible for paying a portion of the charges at the time services are rendered. This is known as the:

co-pay

In many managed care plans, patients are responsible for paying a portion of the charges (fixed amount) at the time services are rendered. This is known as the

co-pay.

The term taht is used to describe the relationship between ICD-10 and CPT codes demonstrating medical necessity is called..

code linkage

Converting narrative diagnoses and procedures into numeric form is known as:

coding

Converting narrative diagnoses and procedures into numeric form is known as

coding.

Which of the following is not a vital sign complete blood count

complete blood count

Which of the following is not a vital sign?

complete blood count

A formal, written document that describes how a physician's practice or hospital ensures that rules, regulations, and standards are being adhered to is known as what kind of plan?

compliance plan

A formal, written document that describes how a hospital or physician practice ensures that rules, regulations, and standards are being adhered to is called alan

compliance plan.

A computerized system which allows physicians to request lab, radiology, or pharmacy services for their patients is known as:

computerized physician order entry

substance abuse, mental health, HIV/AIDS

conditions when a patients records are marked sensitive or restricted

Screenshot from PrimeSuite: What is the reason the patient made an appointment on July 5th,2011?

confusion

What is the reason the patient made an appointment for July 5, 2011? confusion

confusion

The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?

constitutional

How a patient is feeling, any current complaints or concerns, weight loss or gain, appetite, sleep patterns or difficulties, and a recap of vital signs. This information is documented in the general part of the ROS, and is also known as what?

constitutional (or general)

The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?

constitutional (or general)

How a patient is feeling,any current complaint or concerns, wight loss or gain, appetite, sleep patterns or difficulties and a recap of vital signs are documented in the general part of the ROS (review of systems) and is known as _________How a patient is feeling,any current complaint or concerns, wight loss or gain, appetite, sleep patterns or difficulties and a recap of vital signs are documented in the general part of the ROS (review of systems) and is known as _________?

constitutional (or general) -Fill in

Though the costs of implementation will be high, which record-keeping costs will be less as a result of implementing an electronic health record. cost of folders and clips to file each record

cost of folders and clips to file each record

The process of insuring a care provider has the proper qualifications to a medical practice before giving him privileges is ...?

credentialing

A local news paper reporter has contacted your office requesting the total number of patients in the practice who have had a diagnosis of lime disease broken into three age ranges; newborn-18, 19-50, 51 and older. They are grouped by zip code. To answer this inquire your office manager will run which type of report?

custom report

Dr. A prefers to see the Face sheet of her patients in a particular order. Dr. B prefers to see his in another order. The software used in their office allows each provider to view screens in a different way. This is known as:

customization

Dr. Schultz has just examined Natalia Shrier who had come to see him because she has been having increasing problems with gastroesophageal reflux. Dr. Schultz has instructed Natalia to avoid hot, spicy foods, to avoid eating within three hours of going to bed, to raise the head of her bed, and has given her an order to have an Upper GI x-ray. Dr. Schultz's instructions are part of which element in a SOAP note? a) Subjective b) Objective c) Assessment d) Plan

d) Plan The treatment instructions given and the order for an x-ray are part of the physician's plan of care, otherwise known as the Plan in a SOAP note.

The ____ is a form used to bill inpatient claims. a) CMS-1500 b) ICD-9 c) CPT d) UB-04

d) UB-04 The UB-04 form is used to bill inpatient claims.

Blocking access to a facility's computer systems by unauthorized users is accomplished through use of _______________. a) passwords b) special hardware c) encryptor programs d) a firewall

d) a firewall

PrimeSUITE: a) allows for ePrescribing b) assists in information exchange c) has mobile applications d) all of the above

d) all of the above PrimeSUITE is compatible with each of the listed functions.

Which of the following is an advantage of dictation and transcription? a) most physicians prefer it to any other method of documentation b) very inexpensive as compared to written notes c) saves on paper and supplies as compared to speech recognition d) allows for greater accuracy than written notes

d) allows for greater accuracy than written notes

A report that is run on demand is created: a) at the end of each month b) at the end of each quarter c) yearly d) as it is needed

d) as it is needed

A/an ______________________ includes reminders and alerts, diagnostic and therapeutic guidance and links to expert resources. a) registry b) index c) medical dictionary d) clinical decision support

d) clinical decision support

In a ___________ environment, the physician's office or hospital has the advantage of unlimited processing and storage capacity. a) VPN b) local area c) wide area d) cloud

d) cloud

Which of the following is not a vital sign? a) heart rate b) blood pressure c) body mass index d) complete blood count

d) complete blood count A complete blood count is a laboratory test, not a vital sign.

A staff member who monitors existing and new regulations and is the "go-to" person should an incident occur is known as the _____________________. a) office manager b) HIM department director c) managing partner d) compliance officer

d) compliance officer

What is the reason the patient made an appointment for July 5, 2011? a) COPD b) hypertension c) lumbago d) confusion (Insert photo)

d) confusion The patient's chief complaint is confusion, and that is the reason she had an appointment on July 5, 2011.

The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)? a) musculoskeletal b) gastrointestinal c) neurologic d) constitutional

d) constitutional Vital signs, general health, and weight changes are all part of the constitutional findings in the ROS.

Diagnostic and treatment protocols that are based on proven research and practice are known as: a) clinical-based medicine b) decision-based medicine c) data-based medicine d) evidence-based medicine

d) evidence-based medicine

Expected methods of payment are discussed when a patient: a) checks in. b) is seen by the provider. c) is discharged. d) makes an appointment.

d) makes an appointment.

A patient with knee pain has been using pain patches to alleviate the pain; she has been using the kind that are left on the area for several hours. Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI). a) location b) timing c) severity d) modifying factors

d) modifying factors She tried to manage the pain herself with the pain patches, but they were only partially successful, therefore this would be a modifying factor.

Which of the following typically would not be collected as part of the past surgical history? a) name of operation b) name of surgeon c) approximate date of the operation d) name of the anesthesiologist

d) name of the anesthesiologist

The ________ is usually the person to set up information libraries within Practice Management software programs. a) care provider b) healthcare professional c) medical assistant d) office manager

d) office manager An office manager is typically responsible for setting up information libraries in practice management software.

In which healthcare setting is a patient not registered prior to receiving care? acute care hospital a) physician's office b) dental office c) both acute care hospital and dental office d) patients are registered in all of these settings

d) patients are registered in all of these settings. Patients in all settings must be registered before being seen initially, and then at the time each visit or stay takes place

The chronological listing of all newborns at a hospital is known as a _____________. a) index b) custom report c) standard report d) registry

d) registry

A functionality of an EHR or other software that allows the user to assign an electronic "to-do" list to themselves or other employees is known as the: a) calendar b) notebook c) alert system d) task list

d) task list

When planning for a conversion to the electronic health record, administrative members of the staff should expect that: a) the process will be easy and fast b) the conversion will take less time than expected c) no paper records will exist effective on the day of conversion d) the conversion will take more time than expected

d) the conversion will take more time than expected

Depending on the terms of a patient's insurance coverage, the balance remaining after insurance has paid may be: a) written off as paid in full. b) removed from the master index. c) sent to collections. d) written off as paid in full or sent to collections.

d) written off as paid in full or sent to collections.

Of the following, who will benefit from throughly completed paper forms? a. Care providers b. Patients c. Receptionists d. All of these

d. all of these

PrimeSUITE's reports can be used to: a. justify the cost of new equipment. b. perform quality checks. c. track care provider data. d. all of these

d. all of these

What information should you see on all forms in a patient chart? a. name b. DOB c. medical record number d. all of these

d. all of these

Which of the following stakeholders are served by the Health Information Management profession? a. Patient care organizations b. Payers c. Research agencies d. all of these

d. all of these

Which of the following is an acceptable way of gathering a patient's history? a. Assessment b. Critique c. Discussion d. Interview

d. interview

Dr. Rodrique prefers to monitor his practice compliance with meaningful use requirements. He can do this quickly and easily by using prime suites____?

dashboard - Fill in

In order for ACOs to prove that they have provided quality care while controlling costs, what is/are necessary?

data

Susan is collecting data from a patient, and she asks him for his address. The patient asks whether she means his P.O. box number or his physical street address. Susan would find the meaning of the field permanent address in the practice's ______________________.

data dictionary

Susan is collecting data from a patient. She asks him for his address. The patient asks whether she means his PO box or his physical street address. She would find the meaning of the field "permanent address" in the practices..

data dictionary

In order for ACOs to prove that they have provided quality care while controlling costs, what is necessary?

data. Data is necessary to prove that the ACO member organizations are able to coordinate care, show minimal duplication in testing, and the ability share health information.

PrimeSUITE uses a single database to document administrative and clinical data on each patient.

database

Master files are __________________ that provide structure and are the building blocks for parts of a provider's chart notes.

datasets

Of the following, which is not a reason that the United States did not implement ICD-10 at the time other countries did?

decision whether ICD-10 or CPT would be used to code diagnoses

When an encrypted message is sent, it must be ___________ before the receiver is able to read it.

decrypted

In the field "Primary Language", English appears in the field. This is known as a ___________ value.

default

When certain fields are clicked, the most common response to that field may appear. This is known as a _________ value.

default

When certain fields are clicked, the most common response to the field may appear. This is known as a __________ value?

default

Pieces of data that identify a patient and include such terms as name, address, date of birth are considered ______ data?

demographic

Pieces of data which identify a patient and include such items as name, address, and date of birth are considered what types of data?demographic

demographic

Danielle ran a report of congestive heart failure patients. This report includes patient medical record numbers, ages, admission and discharge dates and attending physicians. What type of report is this?

detailed

PrimeSUITE allows you to note discrepancies in the _______ box.

details

PrimeSUITE allows you to note discrepancies in the _________ box.

details

PrimeSUITE allows you to note discrepancies in the details box.

details box

John Smith was admitted to Memorial Hospital on June 6 and died while in the hospital, on June 10. The action taken on June 10 was a/an:

discharge

John Smith was admitted to Memorial Hospital on June 6 and died while in the hospital, on June 10. The action taken on June 10 was a/an: discharge

discharge

John Smith was admitted to Memorial Hospital on June 6 and died while in the hospital, on June 10. The action taken on June 10 was a/an:

discharge Though Mr. Smith died, this was still a discharge since he no longer occupied a hospital bed.

In a hospital a _______ registry is maintained daily and includes all in-patient who have left the hospital at the conclusion of their stay?

discharge -Fill in

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?

discharge summary

6 years

documentation and record retention must maintain for

Any discrepancies in a patient information need to be

documented

Any discrepancies in patient information need to be documented

documented

Any discrepancies in patient information need to be:

documented

Which of the following is a benefit of voice recognition?

documents are made part of the patient's record in a timelier manner

Which of the following statements accurately describes duplicate patient registration in an electronic health record system?

duplicate patient records can occur if the patients name was misspelled of the patient was previously registered under a different name

Which of the following statements accurately describes duplicate patient registration entries in an electronic health record system duplicate patient registrations can occur if the patient's name was misspelled or the patient was previously registered under a different name

duplicate patient registrations can occur if the patient's name was misspelled or the patient was previously registered under a different name

Which of the following is an element of the history of present illness?

duration

CPT codes are used to capture the face-to-face time spent between a patient and the care provider.

e Evaluation and management

The term used to describe the relationship between ICD-10 and CPT codes, demonstrating medical necessity,

e code linkage.

Which of the following EHR applications may be more beneficial and efficient for the patient ePrescribing

ePrescribing

Which of the following EHR applications may be more beneficial and efficient for the patient?

ePrescribing

Amy Shaw arrives for her appointment at Dr. Rodriguez's office. She has moved since her last visit and her last name has changed due to her marriage. The healthcare professional will edit the patient's demographic information.

edit

edit. The process of updating demographic information is known as editing.

Roberta is going over the form with a patient; the form includes such information as the name of the patient, the provider's name and NPI number, the date of the visit, numeric codes corresponding to the patient's diagnoses and procedures performed that day. This form is called a Superbill, and is otherwise known as what?

encounter form

The source document for completing the actual insurance claim form is the:

encounter form

What is the process whereby electronic transmission of any health information sent in such a way that it cannot be read without a special code that reads it______?

encryption -Fill in

____________________ CPT codes are used to capture the face-to-face time spent between a patient and the care provider.

evaluation and management

Care providers use ____ as a way to support their decisions and diagnoses.

evidence-based medicine

Diagnostic and treatment protocols that are based on proven research and practice are known as ____?

evidence-based medicine

Diagnostic and treatment protocols that are based on proven research and practice are known as:

evidence-based medicine

Care providers use _______ as a way to support their decisions and diagnoses.

evidence-based medicine.

A patient's vital signs are entered via PrimeSUITE's ____ screen.

facesheet

A patient's vital signs are entered via PrimeSUITE's ___________ screen.

facesheet

What is the name of the screen that is open facesheet

facesheet

screenshot: What is the name of the screen that is open above?

facesheet

What is the name of the screen that is open?

facesheet In the center of the Page, near the top, the word Facesheet appears.

The patient's ____ history could possibly help predict a future health condition.

family

The patient's __________ history could possibly help predict a future health condition.

family

The patient's family history could possibly help predict a future health condition.

family history

What information within the history may be a predictor of the patient's future health?

family history

The amount charged for each service provided in a medical practice is known as a/an:

fee schedule

An on-screen item of data is known as a:

field

You have just entered data into an online form. The box in which you entered the information is known as a field

field

You have just entered data into an online form. The box in which you entered the information is known as a/an

field

You have just entered data into an online form. The box in which you entered the information is known as a/an:

field

An on-screen item of data is known as a field.

field.

An on-screen item of data is known as a:

field.

Form from Greensway medical group (Medical History form): Typically, paper health records are maintained how?

filed in folders in numeric or alphabetic order

Typically, paper health records are maintained how?

filed in folders in numeric or alphabetic order Paper records are filed in the facility where they originated, alphabetically by patient's last name or numerically by health record number.

Of the following which is NOT a core of function of the EHR as defined by the institute of medicine?

filing of insurance claims

Of the following, which is not a core function of the EHR as defined by the Institute of Medicine?

filing of insurance claims Though filing of electronic claims is part of administrative processes and reporting, it is not specifically one of the eight functions.

When an alert is created, specifying a detail such as "search for patients 30 years or older" is an example of using a/an

filter

When an alert is created, specifying a detail such as "search for patients 30 years or older" is an example of using a/an:

filter

When an alert is created, specifying a detail such as "search for pt 30 years or older" is an example of using a/an:

filter

A ________________ is a security method that prevents unauthorized access into or out of the network.

firewall

Blocking access to a facilities computer systems by unauthorized users is accomplished through the use of _____?

firewalls

A ______ is a security method that prevents unauthorized access into or out of the network?

firewalls - Fill in

Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness, May 13, 2013, inpatient for pneumonia, and once on June 4, 2013 in the emergency department for a sprained arm. How many encounters for Daniel Allen will be found in the MPI of Greenway Hospital? five

five

Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness; May 13, 2013, inpatient for pneumonia; and June 4, 2013, emergency department for a sprained arm. How many encounters for Daniel Allen will be found in the MPI of Greenway Hospital?

five

five. Daniel Allen's name and identifying information should only be found once in the MPI, but each visit is an encounter and there will be a record of each of those encounters in the MPI.

A Patient has requested to be put on a payment plan for her outstanding balance. She came to the office today and while registering her, the healthcare professional saw a dialogue box which alerted her not to collect a late fee. This reminder is known as a ______________.

flag

Jane Howard often misses appointments; an alert is set to appear on her record; this alert is known as a/an ________ in PrimeSUITE.

flag

Jeannie Clark has requested to be put on a payment plan for her outstanding balance. She came to the office today and while registering her, the healthcare professional saw a dialogue box which alerted her not to collect a late fee. This reminder is known as a ______________. flag

flag

Some EHR software includes a method to remind staff to perform certain tasks, for example a clinical alert or to collect a co-pay. In PrimeSUITE the reminder is made in the form of a ___________ that appears as an alert.

flag

The last step in the revenue cycle is

follow up payments and collections.

The last step in the revenue cycle is to...

follow-up on payments and collections

The last step in the medical billing cycle is:

follow-up payments and collections

Every form should include the ___________, so that the forms use is obvious.

form name

Every form should include the _______________ so that the form's use is obvious.

form name

Every form should include the form name so that the form's use is obvious.

form name

Billing for services that are not medically necessary or that did not happen at all is ____________.

fraud

Knowingly billing for services that are not medically necessary or that did not happen at all is

fraud.

The Patient Centered Medical Home (PCMH) model and managed care insurance plans encourage patients to have a primary care physician who is referred to as the __________________ to reduce redundancy and overutilization of medical services.

gatekeeper

The Patient-Centered Medical Home Model and managed care insurance plans encourage patients to have a primary care physician, who is referred to as the ______ to reduce redundancy and over utilization of medical services?

gatekeeper -Fill in

A credentialing requirement is:

having malpractice insurance

A credentialing requirement is:

having malpractice insurance.

The field that focuses on capture, retrieval, storage, and use of health information is

health information

The staff of the ___________________ will need to enter, maintain, and retrieve data from electronic health records within a hospital setting

health information department

The staff of the __________health information department_________ will need to enter, maintain, and retrieve data from electronic health records within a hospital setting.

health information department

The staff of the ___________________ will need to enter, maintain, and retrieve data from electronic health records within a hospital setting.

health information department A hospital's health information department is responsible for EHR-related duties.

Robert Fitzsimmons is an administrator with the local hospital. His responsibilities include the maintenance and security of all of the automated systems that affect individual departments as well as the electronic health record. Mr. Fitzsimmons is a/an:

health systems administrator Though a hospital's health information department is responsible for many EHR-related issues, it is the health systems administrator who is responsible for all of the technological aspects of automated systems within the hospital.

In a hospital setting, the care provider takes the patient's history, details the reason the patient is being admitted and performs a physical exam. The report of this information is known as the:

history and physical

Until recent years, Registered Health Information Technicians, Registered Health Information Administrators, and Certified Health Data Analysts typically worked in which type of facility?

hospitals Though the credentialed individuals may work in any healthcare setting, they are most commonly employed by acute care hospitals. (Note - this information is found in table 2.1.)

Which of the following is not a benefit of an electronic health record, according to the Greenway Medical web demonstration? improved retention of staff

improved retention of staff

all of these

in the event of a breach, who may be held responsible?

providers, office staff, the facility

in the event of a breach, who may be held responsible?

Some care providers enter into an agreement with managed care plans whereby the provider agrees to provide medical services to plan enrollees at a pre-negotiated rate. The providers are considered to be:______?

in-network providers

A PCHM focuses on ________ communication between patients and providers.

increased

A PCMH focuses on ____ communication between patients and providers.

increased

The management of the automated processes that focuses on structure of data, interoperability, design of input and output tools, and security is known as health __________________.

informatics

The management of the automated processes that focus on structure of data, interoportability, design of input and output tools and security is known as health ____?

informatics -Fill in

The progress note of Amy Shaw states that she is a 51 year old female who has a history of lower back pain following a fall off a ladder in 2007. She has been taking ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs to miss work. Based on her history and the results of the physicians exam, the treatment plan is going to be Naproxin daily and an order for physical therapy to include TENS treatment with follow-up visits scheduled in four weeks. This is an example of ......?

information

The progress note of Amy Shaw states that she is a 51-year-old female who has a history of lower back pain following a fall off a ladder in 2007. She has been taking ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs to miss work. Based on her history and the results of the physician's physical exam, his treatment plan is naproxen sodium daily and an order for physical therapy to include TENS treatments with follow-up visit scheduled in four weeks. This is an example of a patient's health _______________________.

information

information The individual pieces of data (age, medical history) give the physician the information he needs to determine a treatment plan.

Each time a patient presents for care, the __________ should be viewed or copied to ensure accurate information is on file for billing purposes?

insurance card

Each time a patient presents for care, the insurance card should be viewed or copied to ensure accurate information is on file for billing purposes.

insurance card

Each time a patient presents for care, the ______________ should be viewed or copied to ensure accurate information is on file for billing purposes.

insurance card.

Of the following, which would be a library used in the accounts receivable functions of a practice management system?

insurance company names

Roberta is a billing coordinator at Greenway Medical Center. She is in the process of determining whether a patient is covered by insurance, whether a co-payment is due, and whether the patient has met his deductible. What function is Roberta performing?

insurance verification

Data that is timely, consistent, secure, and correct is said to have data __________________?

integrity -Fill in

Dr. 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 one another without duplicating data entry. The systems are able to: interface

interface

In order for Dr. Reynolds to send a CPOE from her office computer system to the computer system at the local hospital a ______ must exists between the two computer systems?

interface

In order for Dr. Reynolds to send a CPOE from her office computer system to the computer system at the local hospital, a/an ____________________ must exist between the two computer systems.

interface

What is required in order for computerized physician order entry to occur between different healthcare facilities?

interface

Dr. 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 one another without duplicating data entry. The systems are able to

interface.

interface. An interface allows different software packages to communicate without re-entering data.

During the history of present illness, the healthcare professional asks Ron Albertson for his preferred pharmacy. The healthcare professional then enters the information into PrimeSUITE. After the care provider has examined and diagnosed Mr. Albertson, he prescribes Amoxicillin and electronically sends the prescription to Mr. Albertson's chosen pharmacy without having to enter any additional information into the ePrescribe module. This is an example of: interoperability

interoperability

Many offices use an internal, secure environment to communicate important information to their employees. This is known as a/an?

intranet

directory information

is a listing of patient information, such as the hospital room number.

One of the reasons ePrescribing is being used by a greater number of physicians' practices is that it:

is a requirement of the HITECH Meaningful Use regulations.

One of the reasons ePrescribing is being used by a greater number of physicians' practices is that it:

is a requirement of the HITECH Meaningful Use regulations. In order for physicians to receive incentive money from the HITECH Act, they must show that the electronic health record is being used in a meaningful way. Electronically prescribing medications is one way that improves accuracy, monitors for drug interactions, and improves efficiency.

the audit Trail

is the permanent record of all accesses, changes, and deletions made to the health record. It is available even after files are deleted.

Which of the following is a true statement about using practice management software for an office's claims management process?

it allows for more efficient tracking and reporting of daily transactions

off-site

it is crucial that files be stored

"Of the following, which is not a benefit of ePrescribing? A. the patient's demographic and insurance information is sent to the pharmacy from the office B. there is less chance of medication errors being made C. it is less expensive for the patient D. care providers and pharmacists are alerted to possible food/drug or drug/drug interactions

it is less expensive for the patient

Of the following, which is not a benefit of ePrescribing?

it is less expensive for the patient

confidentiality

keeping information about the patient to oneself is

The "box" where data is entered on an electronic medical record, for instance Patient's Last Name, is commonly called a field. What is the other name for field?

label

The "box" where data is entered on an electronic medical record, for instance the patients last name is commonly called a field or _______. What is the other name for a field?

label - Fill in

You are about to enter the marital status of a patient, and upon clicking in that field, the following appears: These possible values are derived from a _____________ within the system.

library

All of the insurance companies and the individual plans of patients in the medical practice are included in what database of the practice's practice management software?

library of insurance companies

Tiffany Randall is seen by her physician after falling off a piece of playground equipment. She has a laceration on her chin. This is part of which element of the history of present illness?

location of the injury

Tiffany is seen by her physician after falling off a piece of playground equipment. She has a laceration on her chin. This is part of which element of the history of present illness?

location of the injury -Fill-in

It is important to keep the design of paper forms

logical

It is important to keep the design of paper forms:

logical

It is important to keep the design of paper forms logical.

logical.

Greenway Medical Center uses a priority ranking system for their internal e-mail. The fact that the holiday luncheon will be held on December 6, 2011 would be a __________ priority email.

low

Care providers who contract with insurance carriers typically agree to a ______ rate of reimbursement for those services.

lower

The actual claim process begins when the patient:

makes the appointment

The type of insurance plan that promotes quality, cost-effective healthcare by monitoring patients, encouraging preventive care, and requiring performance measures of physicians is known as:

managed care

Of the following, which is not part of the patient's past medical or surgical history marital status

marital status

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

marital status

What is the patient's marital status? married

married

What is the patient's marital status? Insert picture

married. Looking at the social history, it is noted that the patient is married.

Datasets that provide structure and are the building blocks for parts of the health record are known as ____________ files.

master

Datasets that providers structure and are the building blocks for parts of the health record are known as _______ files?

master -Fill in

The review of systems menu choices are in PrimeSUITE is an example of a/an

master file

The Review of Systems menu choices in PrimeSUITE are an example of a/an:

master file.

certified

meaningful use standards require offices to select an EHR that is

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

medical (health) record number

In a hospital, what piece of data included in master patient (person) index (MPI) which allows a hospital to locate the corresponding health (medical) record for each patient?

medical (health) record number. Each patient is assigned a medical record number for identification and filing purposes, and is found in the MPI.

Roberta has an associate degree and holds RMA certification. She mainly performs administrative duties such as appointment scheduling, registering patients, and maintenance of health records in a large physician's practice. She occasionally performs clinical duties as well, as needed. Roberta is a .....?

medical assistant

Which of the following professionals would not perform a physical examination (PE)?

medical assistant

medical assistant. A registered medical assistant performs the typical administrative duties of a regular MA, with the added ability to handle periodic clinical duties.

An ROS covers information likely documented in the

medical history exam

A ROS covers information likely documented in the:

medical history form

An ROS covers information likely documented in the:

medical history form.

In a hospitals health information department, patient records are most often filed by

medical record number

In the CPOE standard, Stage 1 only addressed

medication orders

In the CPOE standard, Stage 1 only addressed:

medication orders

modifying factor

The fact that a patient has taken an over the counter medication, and did receive relief of his pain. This is known as a/an what in relation to subjective documentation found in this patient'

modifying factor

modifying factors

The more voice recognition software is used, the

more it learns voice inflection

The more voice recognition software is used, the

more it learns voice inflections.

The more voice recognition software is used, the:

more it learns voice inflections.

Which of the following typically would not be collected as part of the past surgical history?

name of the anesthesiologist

Which of the following typically would not be collected as part of the past surgical history? name of the anesthesiologist

name of the anesthesiologist

Jeannie Lopez has never been seen in Greensburg Medical Center. The evaluation and management code assigned will be based on the fact that she is a/an ___________ patient.

new

Philip James has been a patient at Greensburg Medical Center for three years. During that time he has been seen twice for annual physical exams, three times for ear infections, and four times for follow-up of his hypertension. How many encounters does Mr. James have at Greensburg Medical Center?

nine (9)

Information gathered during a provider's physical exam would appear in the ___ section of a SOAP note.

objective

Information gathered during a provider's physical exam would appear in the ___________ section of a SOAP note.

objective

Information gathered during a provider's physical exam would appear in the ____________ section of a SOAP note.

objective

The results of a patient's rapid strep test would be found in what area of a SOAP note?

objective

The results of a patients rapid stress test would be found in what area of a SOAP note?

objective

job description

of the following which factor contributes to the access rights allowed a user

job description

of the following, which factor contributes to the access rights allowed to the user?

In a physicians practice ___________ may be the title of a person responsible for the overall administrative management of the practice?

office administrator

A patient at Heller Memorial Hospital, Lisa Ford, was a patient in the emergency department in 1998 and has had outpatient lab work in 2003 and 2005; she was then married. Her name changed to Lisa Ford Haver, and she had her twins at Heller County Memorial Hospital in 2010. How many times will her name and demographic information appear in the hospital's MPI?

once

A patient at Heller Memorial Hospital, Lisa Ford, was a patient in the emergency department in 1998, has had outpatient lab work in 2003 and 2005; she was then married. Her name changed to Lisa Ford Haver, and she had her twins at Heller County Memorial Hospital in 2010. How many times will her name and demographic information appear in the hospital's MPI? once

once

A patient at Heller Memorial Hospital, Lisa, was a patient in the emergency department in 1998 and has had outpatient lab work in 2003 and 2005. She was then married. Her name changed to Lisa Ford Haver and had her twins at Heller County Memorial Hospital in 2010. How many times will her name and demographic information appear in the hospitals MPI(master patient index)?

once

once. Though she has been seen in the hospital numerous times and has been seen under two different names, as a patient she will only appear once.

Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness, May 13, 2013, inpatient for pneumonia, and once on June 4, 2013 in the emergency department for a sprained arm. How many times will Daniel Allen's name and demographic information be entered in the MPI of Greenway Hospital? one

one

Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness; May 13, 2013, inpatient for pneumonia; and June 4, 2013, emergency department for a sprained arm. How many times will Daniel Allen's name and demographic information be entered in the MPI of Greenway Hospital?

one

Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness, May 13, 2013, inpatient for pneumonia, and once on June 4, 2013 in the emergency department for a sprained arm. How many times will Daniel Allen's name and demographic information be entered in the MPI of Greenway Hospital?

one. Regardless of the number of times the patient is seen, he/she is entered only one time in the MPI.

Which of the following elements of an HPI are collected at a visit?

only those that apply to the patient's chief complaint

What is the name of the technology used to scan images and then convert them to a format that is readable by the computer?

optical character recognition

What is the name of the technology used to scan images and then convert them into a format that is readable by the computer?

optical character recognition -FIll in

In PrimeSUITE, as with many other electronic health record systems, healthcare professionals and healthcare providers can access a patient's health record to determine the status of orders for testing or prescriptions. This is known as:

orders tracking

healthcare professionals and healthcare providers can access a patient's health record to determine the status of orders for testing or prescriptions. This is known as:

orders tracking

A facility needs to make sure that the information on their intranet does not become:

outdated

When collecting data on a computer or retrieving data from a computer, the screen becomes the replacement for ______________.

paper

When collecting data on a computer or retrieving data from a computer, the screen becomes the replacement for paper

paper

When collecting data on a computer or retrieving data from a computer, the screen becomes the replacement for ______________.

paper Rather than writing or reading from a piece of paper, or typing the physician's dictation into a transcribed paper report, data is found on the computer screen.

Would be found in which format paper health record

paper health record

Who is responsible for maintaining a personal health record?

patient

In a medical office a standard report that runs shows how much each patient owes is the _____?

patient balance

Using templates makes it easier for care providers to focus on their first priority, which is

patient care

In a physician's office, the equivalent of a hospital's master patient index is a/an:

patient list In a physician's practice, the list of all patients ever seen in the office is most commonly referred to as the patient list.

In a physician's practice, the index of all patients seen in that practice is most commonly known as the

patient list.

As part of Greensburg Medical Center's electronic record, patients can access their own health records via the Internet and can email the office with questions. This functionality is ______?

patient portal

As part of Greensburg Medical Center's electronic record, patients can access their own health record via the Internet and can e-mail the office with questions, when necessary. This functionality is called a/an

patient portal.

The step that occurs after a patient is seen by the care provider is: patient stops at the cashier or check-out desk

patient stops at the cashier or check-out desk

What is the step that occurs after a patient is seen by the care provider?

patient stops at the cashier or check-out desk

The step that occurs after a patient is seen by the care provider is

patient stops at the cashier or check-out desk.

The step that occurs after a patient is seen by the care provider is:

patient stops at the cashier or check-out desk.

The extent of a physical exam largely depends upon which of the following?

patient's chief complaint

There are certain pieces of data that must be collected in order to meet Meaningful Use requirements. Which data element below does that?

patient's race

In which healthcare setting is a patient not registered prior to receiving care?

patients are registered in all of these settings

In which healthcare setting is a patient not registered prior to receiving care? patients are registered in all of these settings

patients are registered in all of these settings

Where do the data originate that are used to prove accountable care organization success?

patients health records

audit Trail

permanent record of changes made to various documents; available even after files are deleted

The MPI and patient list should be kept.....?

permanently

The MPI and patient list should be kept

permanently.

A record that contains a person's health history, allergies, current complaints, past medical and surgical history, and a listing of current medications, but is not considered a legal health record is a/an:

personal health record Patients may compile their health related information using summary medical reports; because it is incomplete and unofficial, it cannot be considered a legal document.

A record that contains a persons health history, allergies, current complaints, past medical and surgical history and a listing of current medications but is not considered a legal health record is a.......

personal health record (PHR)

A good practice for healthcare consumers is to document their own health information, for instance, the medications currently being taken, medication allergies, dates and names of surgeries they've had, etc. In fact, many insurance companies offer their patients the ability to document their healthcare online. What are these records known as?

personal health records

Robin Molon needs to determine the total number of patients assigned to eachcare provider for a report to blue shield. What type of index should she run?

physician or provider index

The SOAP documentation format is most commonly used in which healthcare setting?

physician's office

The SOAP documentation format is most commonly used in which healthcare setting?

physicians office

plan

Notes about a prescription ordered for a patient would appear in the ___________ section of the SOAP note.

plan

Notes about a prescription ordered for a patient would appear in the ____ section of a SOAP note.

plan

Notes about a prescription ordered for a patient would appear in the ________ section of a SOAP note.

plan

disaster recovery

plan is written document that details hardware and software inventory, locations of backups, and procedures to be used in event of a crisis?

In healthcare, when something is occurring at the time the patient is being seen, such as in ePrescribing, this is known as ____________________.

point of care documentation

poison ivy

Emily is being sent to Dr. Clark today for her annual physical. She's been a patient of his for many years. She is currently being treated for hypertension and type 2 Diabetes. In the late 90's she was treated on several occasions for poison ivy. She has been treated since 2003 with Zoloft for mild depression. Of the following which will not appear on her problem list?

poison ivy

true

policy should be kept in the location accessible to all office staff

It is ____ to have too many flags set up in PrimeSUITE

possible

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

practice management

Which of the following is NOT an example of demographic data?

primary physician

Meaningful USE regulations require the keeping of an up-to-date

problem list

Meaningful Use guidelines require the keeping of an up-to-date:

problem list

Meaningful use regulations require the keeping of an up-to-date:

problem list

Meaningful Use regulations require the keeping of an up-to-date

problem list.

In a physicians practice the documentation of a physicians office visit is often refereed to as a ...?

progress note

Information that identifies the patient in any way is known as _________________.

protected health information

Information that identifies the patient in any way is known as protected health information

protected health information

Information that identifies the patient in any way name, age, phone number, address, medical record number is called ........?

protected health information

Information that identifies the patient in any way is known as _________________.

protected health information Protected health information is any information, such as name, address, phone number, or medical information, that identifies the patient.

The name, address, NPI number, and telephone number of a physician is known as ____________ information.

provider

The name, address, NPI number, and telephone number of a physician is known as ____________ information.

provider. A physician is also known as a provider

The Internet is ________ and an intranet is ________ .

public; private

During the history, Kevin Goodell notes that the pain in his right hip is more of a dull pain than an ache. This is considered what part of the history of present illness (HPI)?

quality

"Of the following, which is not an element of the history of present illness (HPI)? A. duration B. severity C. quantity D. quality

quantity

Of the following, which is not an element of the history of present illness (HPI)?

quantity

There are certain pieces of data that must be collected in order to meet Meaningful Use requirements. Which of the following data does that?

race. Meaningful use regulations require the collection of patients' race and ethnicity.

The amount of time allotted for a patient's office appointment is largely dependent on the _______________________.

reason for the visit

The amount of time allotted for a patient's office appointment is largely dependent on the reason for the visit

reason for the visit

The amount of time allotted for a patient's office appointment is largely dependent on the _______________________.

reason for the visit. The reason for the visit largely affects the amount of time allotted for the appointment. The fact that a patient is new does not necessarily mean a longer appointment than for an established one.

Before a patient can be treated at a healthcare setting, she must be

registered

In a hospital setting, when the patient presents for care he/she is:

registered

In a hospital setting, when the patient presents for care he/she is: registered

registered

In a hospital setting, when the patient presents for care he/she is:

registered Since patients most often do not actually schedule appointments to be seen in a hospital, they are registered rather than scheduled for an appointment.

breach of confidentiality

releasing information without proper required authorization is called

An insurance company submits payment to a medical practice, along with a document that details the patients and accounts for which payment is made. This document is called the

remittance advice.

HIPPA rules

require a contract between covered entities & business associates Safeguard the PHI

Of the following, which contributes to the high cost of electronic health records for the software service provider? research and development costs

research and development costs

The quality of a digital image is known as the:

resolution

respiratory

If a computerized physician's order is sent to the local hospital for a blood test, and the physician's office has already been notified of the test findings, this order is:

returned

review of systems

A hard copy document such as an insurance card may be converted to digital format for inclusion in a patient's health record. The process of converting the document from paper format to digital format is known as _________________.

scanning

The charge for each service (by CPT code) provided in a medical practice is known as the fee ________________.

schedule

The charge for each service by CPT code provided in the medical practice is known as the fee ___

schedule -Fill in

Virginia Reed called Greensburg Medical Center to make an appointment for her annual physical exam. This step in the process is called

scheduling.

Which of the following PrmeSUITE functions may be customized by a user?

screen layout

Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _____________ are assistants who may enter the information.

scribes

A patient states that her pain is an 8 on a scale of one to ten. This is known as the ___________ in a history of present illness?

serverity

A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI).

severity

_________________ make it possible for care providers to make and receive phone calls, browse the Internet, take still pictures or video, and store telephone numbers and appointments.

smartphones

Sarah Armel has been a smoker for 15 years. She smokes 1 pack per day. This is noted in which section of Sarah's history?

social history

Which of the following would include a patient's exercise regimen?

social history

business associate

someone who uses PHI on behalf of an entity

Relating to dictation, the technology that does not recognize individual voices and does not improve over time is which kind of technology?

speech recognition technology

The largest advantage of voice recognition software over manual transcription is

speed of turn-around time

The biggest advantage of voice recognition software over manual transcription is

speed of turn-around time.

The biggest advantage of voice recognition software over manual transcription is:

speed of turn-around time.

PrimeSUITE's referring provider report is an example of a

standard

authentication protocols

stats the EHR system requires users to take before it will accept their log in and save the data that are entering into the patient

A zip code would be an example of _______________ data.

structured

A zip code would be an example of _______________ data.

structured A zip code equates to a particular municipality; because it is in coded format, it is structured data.

The date of birth on a patient's record is ___________________ data.

structured Because the date of birth is entered in a pre-defined manner, for instance MMDDYYYY and can be used to run reports or to extract data, the date of birth is structured data.

A zip code would be an example of structured data.

structured data

Alison just receive a copy of her clinical visit summary from her visit to her primary care provider earlier in the day. She is reading that her symptoms were present for the past four days and that she did not get any relief from motrin. To which section of the SOAP note does this information pertain?

subjective

Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low grade fever for the past four days. This is known as

subjective information

Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low grade fever for the past four days. This is known as _______________.

subjective information

The primary person covered by an insurance plan is the:

subscriber

The primary person covered by an insurance plan is the

subscriber.

A functionality of an EHR or other software that allows the user to assign an electronic "to-do" list to themselves or other employees is known as the:

task list

A healthcare professional may assign work to another user with PrimeSUITE's _____ functionality

tasks

Health informatics is basically the ____ part of managing health information.

technological

Recent advances in healthcare rely increasingly on:

technology

Recent advances in healthcare rely increasingly on:

technology.

John Roberts has a heart condition. A Home Health nurse visits him monthly and performs an EKG, the recording of which is sent to Dr. Stephens' office via telephone connection. This is an example of ____________.

telemedicine

John Roberts has a heart condition. A home health nurse visits him monthly and performs an EKG, the recording of which is sent to Dr. Stevens office via telephone connection. This is an example of _____?

telemedicine

Videoconferencing and remote vital sign monitoring are part of:

telemedicine

Videoconferencing and remote vital sign monitoring are part of:

telemedicine.

Preformatted documents built into the practice management and electronic health record software are known as:

templates

Preformatted documents built into the practice management and electronic health record software are known as:_______?

templates -Fill in

data integrity

the accuracy, timeliness of a collection, consistency of definitions, and expectation of data not having being changed once entered is called

When planning for a conversion to the electronic health record, administrative members of the staff should expect that

the conversion will take more time than expected.

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?

the discharge summary

The feature in Prime Suite that guides the user on how specific functions or applications work is known as...?

the help icon

Which of the following is not part of a paper encounter form (Superbill)?

the medical history

increase the implementation of EHR systems

the mission of CCHIT is to

Which of the following typically would not be collected as part of the past surgical history?

the name of the anesthesiologist

The first step of the information chain in an electronic system is.....?

the patient makes the appointment

Where do the data originate that are used to prove Accountable Care Organization (ACO) success?

the patients' health records

Where does the data originate that is used to prove Accountable Care Organization (ACO) success? the patients' health records

the patients' health records

Where does the data originate that is used to prove Accountable Care Organization (ACO) success?

the patients' health records. The health record is the source document for all data.

The setting where services took place is known as ______________________.

the place of service code

The setting where services took place is known as the place of service code

the place of service code

The setting where services took place is known as ______________________.

the place of service code. Each claim form must include the setting (place) where the services were rendered, known as the place of service code.

The amount of time allotted for a patients office appointment is largely dependent on the ......?

the reason for the visit

secure environment

the sharing of health information must be done in a

Research has shown what, in relation to the use of an EHR there has been decrease in medical errors through use of EHR software

there has been decrease in medical errors through use of EHR software

encrypted

to help guard against security breaches emails containing protective health information should be

encrypted

to help guard against security breaches, emails containing protective health information should be

Nick Malone underwent an appendectomy by Dr. Lopez on September 5. Dr. Lopez documented appendicitis as Mr. Malone's diagnosis. The diagnosis was documented ______________________.

to show medical necessity

Nick Malone underwent an appendectomy by Dr. Lopez on September 5. Dr. Lopez documented appendicitis as Mr. Malone's diagnosis. The diagnosis was documented

to show medical necessity.

"Of the following, which would be included on a remittance advice or explanation of benefits? A. total charges for a patient's account B. subscriber's address C. effective date of insurance D. employer's information

total charges for a patient's account

Of the following which would be included on a remittance advice (RA) or explanation of benefits (EOB)?

total charges for a patients account

Prime Suite has the capability to ____ the status of an order.

track

Prime Suite has the capability to ________the status of an order.

track

PrimeSUITE has the capability to ___________ the status of an order.

track

Meaningful use requires that a practice not only implement at least one clinical support rule, but also:

track compliance

A person hired to manually record a physician's spoken word is known as a:

transcriptionist

A person hired to manually record a physician's spoken words is known as a

transcriptionist

The healthcare professional who types reports for care providers is known as a/an ______________.

transcriptionist

A person hired to manually record a physician's spoken words is known as a

transcriptionist.

Custom reports have at least ___ variable(s) that is/are not available through a standard report

two

Custom reports have at least ____ variables(s) that is/are not available through a standard report.

two

Michael Malone's health (medical) record number at Memorial Medical Center is 482638. This is an example of a/an unique identifier

unique identifier

Michael Molons health or medical record number at memorial medical center is 482638. This is an example of a ....?

unique identifier

Malone's health (medical) record number at Memorial Medical Center is 482638. This is an example of a/an ______________________.

unique identifier. Each patient only has one health (medical) record number at a particular hospital or healthcare facility, therefore it is a unique identifier.

An x-ray of the ankle was performed on Daniel Way on December 16. Dr. Eberly interpreted the x-ray and dictated his impression, which then became part of the hospital's electronic health record. This impression is ________________________ data.

unstructured

Dr. Henderson wrote a progress note in the emergency room for Lisa Ford. This is an example of __________ data?

unstructured

Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Philips, by typing the sentences: "The patient is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He voices no other complaints." This is an example of _________________ data.

unstructured

unstructured The report is unstructured because it contains a narrative of the physician's findings.

Dr. Henderson wrote a progress note in the emergency room note of Lisa Ford. This is an example of _________________ data.

unstructured The report is unstructured because it contains a narrative of the physician's findings.

In order to send and accept diagnosis codes using ICD-10-CM, which version of the HIPAA Code Set rule was effective as of January 1, 2012?

version 5010

In order to send and accept diagnosis codes using ICD-10-CM, which version of the HIPAA Code Set rule was effective as of January 1, 2012? version 5010

version 5010

In order to send and accept diagnosis codes using ICD-10-CM, which version of the HIPAA Code Set rule was effective as of January 1, 2012?

version 5010 There is no version 3010 or 6010; 5010 was the revision to version 4010 of the code set rule.

The patient has a heart rate of 68 and a blood pressure of 110/65. These are known as:

vital signs The data related to vital signs is found under the Vital Signs bar.

Currently, participation in the Physician Quality Reporting Initiative is :

voluntary

Currently, participation in the Physician Quality Reporting Initiative is:

voluntary

hidden

when a document is amended or changed in an EHR, the original documentation is

mitigation

when in violation of the Privacy Rule, the covered entity must make up for harm done

The capturing of data about a patient begins at what point?

when the patient calls for an appointment or arrives at the hospital for care At the time a patient calls the office (or arrives at the hospital) identifying information is collected, which starts the record for that patient.

password

which is a private secure code that allows users to access the computer systems & software

covered entity

which of the following has legal right to access protected health information by virtue of being a healthcare provider, Clearing House, or health insurance plan?

covered entity

which of the following has the legal right to access protected health information by virtue of being a healthcare provider, Clearing House, or health insurance plan?

breach of confidentiality

which of the following is a break or failure of security measures that results in information being compromised?

There must be a(n) ________ available in order for providers to use portable devices to access health information.

wireless connection

There must be a(n) _______________ available in order for providers to use portable devices to access health information.

wireless connection

point of care

with a prescribing, the care provider sends prescriptions to the patient's Pharmacy electronically. This is completed by care provider at

A medical practice or hospital must have _________________ on how to handle inconsistent or unclear information.

written policies

Dr. Henderson's office has been installing an EHR system in their office over the past few months. On January 2, 2014, they will begin using the new system for all patients seen on that date and going forward. Using the system for the first time is referred to as what?

"Going live"

PrmeSUITE's reports can be used to

*ALL OF THESE

Timely Electronic Access

- Provided to Pt upon request - Summary of Problem List, Allergy List, and Medication List

Patient Education

- Written documentation of signs, symptoms, current treatment options, and other pertant information about condition

Healthcare facilities have ___ year[s] after the adoption of an EHR to prove meaningful use.

Healthcare facilities have ____ year(s) after the adoption of an EHR to prove meaningful use

According to the AHIMA practice brief, how soon does the e-HIM taskforce think industry will transition from paper-based to EHR?

10 YEARS

ICD-9-CM had been the coding system used prior to ICD-10-CM. In what year did ICD-9-CM go into effect?

1979

How many surgeries has this patient undergone 2

Penalties for facilities not adopting electronic health records began in ______.

2015

Penalties for facilities not adopting electronic health records will begin in ________.

2015

Regardless of the type of system an organization chooses, they must remember the _____ main components needed for an effective EHR.

increased

A PCMH focuses on ____ communication between patients and providers.

the Privacy Rule

A covered entity must develop and Implement a written policy and procedures and a compliance plan that complies with ___________________.

Registry

A listing that is filed in chronological order based on when something occurred. -examples- birth registry, death registry, or cancer or trauma registry and also immunization records

A remittance advice is typically given to a/an ________ , whereas an explanation of benefits is typically given to a/an ________ . A. patient; provider B. provider; patient C. insurance company; patient D. provider; insurance company

Data

A single fact often used interchangeably with information

An intern is working in the office and the Office Manager at Greenway Medical Center has four tasks for the intern to do today. Rate each of these by low (should be done, but can wait), 2 Medium (does not need to be done within the next few hours, but should not be put off more than a day), and high priority (needs to be done as soon as possible).

A. Medium B. High C. High D. Low E. Low

audit log

A/an _____________records all actions within an EHR that are related to electronic health information

This organization is a health care model whereby a group of physicians, hospitals, and/or other health care providers form a partnership that provides high-quality, coordinated care to a population of patients. What is the name of this organization?

ACO

Besides controlling the safety and cost of medication administration, what other item (s) does a closed-loop medication management system help with?

ADMINISTRATION OF MEDICATION 5 RIGHTS

Demographic data is a subset of what type of data?

ADMINISTRATIVE

This information system supports the daily management-related operations of the health care enterprise such as management, executive decisions and HR.

ADMINISTRATIVE

Which two major types of data are contained in the health record?

ADMINISTRATIVE AND CLINICAL

All of the following are the main components needed for an effective EHR except:

ADMINISTRATIVE DOCUMENTATION

"Fifty percent (50%) of patients treated at our facilities have Medicare as their primary payer." This statement is an example of what type of information?

AGGREGATE

HITECH regulations require that ____ information releases are accounted for.

ALL

In order to transform the vision of information governance from dream to reality, the HIM professional must be eager to

ALL OF THE ABOVE: ADDRESS THE CHALLENGE, REINVENT OUTDATED PROCESSES, TRANSFER THEIR KNOWLEDGE AND SKILLS TO THIS TRANSFORMATION

In order for hospitals or physicians to earn meaningful use, their EHR technology must be

ALL OF THE ABOVE: CERTIFIED, USED IN A MEANINGFUL WAY, INTEROPERABLE

Basic principles of health care documentation addresses all of the following except

ALL OF THE ABOVE: UNIFORMITY, ACCURACY, AUTHENTIITY

In the event of a breach of confidentiality, who may be held responsible for that breach?

ALL OF THESE: OFFICE STAFF, FACILITY, PROVIDERS

In the event of a breach, who may be held responsible?

ALL OF THESE: PROVIDERS, OFFICE STAFF, THE FACILITY

Betsy Johnson is the HIM director of Mercy Care Hospital. It is her task to assure the fee schedules are updated in their system. In order to do this, Betsy has a working knowledge that the fee schedules for third party payers are updated:

ANNUALLY

Data security policies and procedures should be reviewed at least

ANNUALLY

The ambulatory (outpatient) care information system and the acute (inpatient) care information systems use many common functionality features. Choose the function below that is used in ambulatory (outpatient) care information systems that is not used in the acute (inpatient) care information system.

APPOINTMENT SCHEDULING

Which of the following is an example of a technical measure?

ASSIGNING PASSWORDS THAT LIMIT ACCESS TO COMPUTER STORED INFORMATION

Finish this sentence: Management support systems

ASSIST IN ORGANIZATIONAL PLANNING

As the data quality coordinator for your facility, when does your responsibility for data quality begin?

AT THE TIME THE DATA IS COLLECTED

Which term is defined as ensuring timely and reliable access to and use of information?

AVAILABILITY

All

According to HIPPA regulations, healthcare providers must use as opposed to written documentation to store and transmit information to insurance carriers

Greenway Medical Center has partnered with five area physician's offices 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 Accountable Care Organization

Accountable Care Organization

Greenway Medical Center has partnered with five area physician's offices 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 a/an _________________.

Accountable Care Organization

Groups of doctors and other healthcare providers and facilities who voluntarily form a partnership that results in high quality, coordinated healthcare is known as a/an:

Accountable Care Organization

Groups of doctors and other healthcare providers and facilities who voluntarily form a partnership that results in high-quality, coordinated healthcare is known as a/an

Accountable Care Organization.

Accountable Care Organization. Accountable Care Organizations consist of groups of care providers in a coordinated effort to provide quality care while controlling costs.

Data

Accountable care organization rely on EHR_______

Describe accounts receivable.

Accounts receivable tracks the flow of money into a practice from collected payments.

For ease of completion, related information should be ____ on a form.

Adjacent

__________data include demographic data

Administrative

HIPPA

Administrative data is used to satisfy _______requirements

As a result of which piece of legislation are hospitals and providers reimbursed based on proof that they are rendering high quality, coordinated care to their patients?

Affordable Care Act (ACA)

A _______ report shows a total summary but no details?

Aggregate

Which of the following stakeholders are served by the Health Information Management profession?

All of these : Payers Research agencies Patient care organizations

Which piece of information might be included multiple times on a form Allergies

Allergies

ICD-10-CM

Alphanumeric diagnosis codes

Amend the record to show the corrected information, according to office policy.

The Patient-Centered Medical Home was developed by ________?

American Academy of Family Practitioners

The Patient Centered Medical Home (PCMH) model was developed by the ________________.

American Academy of Family Practitioners.

In a hospital setting, the management and much of the staff of the department responsible for entering, maintaining, and retrieving data from health records, are often certified through and members of which professional organization

American Health Information Management Association (AHIMA)

American Health Information Management Association (AHIMA). The AHIMA certifies health professionals who work with health data and information.

Which of the following is not a professional organization related to the fields of health information, medical assisting, or allied health?

American Hospital Association

Which of the following is not a professional organization related to the fields of health information, medical assisting, or allied health? American Hospital Association

American Hospital Association

Which of the following is not a professional organization related to the fields of health information, medical assisting, or allied health?

American Hospital Association The American Hospital Association does not certify individual professions.

The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the American Recovery and Reinvestment Act

American Recovery and Reinvestment Act

The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the _______________________.

American Recovery and Reinvestment Act

The health information technology for economic and clinical health (HITECH) Act is part of......

American Recovery and Reinvestment Act

The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the _______________________.

American Recovery and Reinvestment Act HITECH standards fall under the American Recovery and Reinvestment Act.

What is the name of the document typically sent by insurance companies to a subscriber detailing the services and charges submitted for payment by the medical office, the allowed amount, the co-pay satisfied by the patient, any deductible due, the amount paid by the insurance company and the amount owed by the subscriber?

An Explanation of Benefits (EOB)

What is the name of the document typically sent by insurance companies to a subscriber detailing the services and charges submitted for payment by the medical office?

An Explanation of Benefits (EOB) - Fill in

An alpha-numeric code which corresponds to each diagnosis made by the care provider, and is included on every claim form is known as what kind of code?

An ICD-10-CM code

Center for Medicare and Medicaid Services (CMS)

An agency of the Department of Health and Human Services and responsible for administering the Medicare and Medicaid programs.

What is the first step in the patient flow of information?

An appointment is made. Scheduling an appointment is the first step in patient flow.

CCHIT

An independent organization that is responsible for certifying electronic health records for viability

Institute of Medicine (IOM)

An independent organization that works to provide advice and guidance to the public and healthcare decision makers

The master patient person index is: An index of all patients ever treated in a hospital

An index of all patients ever treated in a hospital

The master patient (person) index is:

An index of all patients ever treated in a hospital. An index of all patients ever treated in a hospital setting is kept in the MPI.

Enter all data correctly

An insurance claim may be denied if the receptionist fails to______________

An insurance company submits payment to a medical practice, along with a document that details the patients and accounts for which payment is made. This document is called the: A. Superbill B. Encounter form C. Remittance advice D. Subscriber benefits notice

Accessible

An office's compliance manual should be kept in a/an location

Once

Anna Jacobs presented to the ER of county hospital 3times in the past year, she will appear in county's MPI how many times

Discuss three advantages to electronic health records as discussed in the text.

Answers may vary, but points such as speed of data transfer, lower long-term costs, eliminating handwriting issues; ability to keep a comprehensive record of patient care and history, and contributions to research and global health care should be listed. There are many advantages to EHRs, such as lower long-term costs, the ability to keep a comprehensive record of patient care, and contributions to research and global health.

Protected Health Information

Any piece of identifying or clinical information about a patient

Detail report

Any report that includes patient identifying information and lists each case individually rather than as totals.

A patient's surgical history includes the

Approximate date of the procedure

When patients are finished with their encounter at a hospital, they:

Are discharged

As a result of which piece of legislation are hospitals and providers reimbursed based on proof that they are rendering high quality, coordinated care to their patients? A. Health Information Technology for Economic and Clinical Health Act (HITECH). B. Health Insurance Portability and Accountability Act (HIPAA) C. Affordable Care Act (ACA) D. Amendment to the Social Security Act

As of October 1, 2015, the coding system used to code diagnoses in any healthcare setting is: rev: 02_27_2015_QC_CS-9167 A. ICD-9-CM B. HCPCS level 2 C. CPT D. ICD-10-CM

The subscriber and patient information section of a claim includes all of the following except...?

Assignment of benefits authorization

Patient demographics information should be verified

At each visit

The CEO of ABC Hospital wants to look at specific information that is affecting the clinical quality, financial viability, customer loyalty, and operational effectiveness of the health care organization. What kind of report (s) might the CEO choose to look at?

BALANCED SCORECARD OR DASHBOARD REPORT

All of the following are considered unstructured data except:

BAR CODES

Today, most hospitals are moving to a ___________ system to dispense medications within the acute care setting

BC-MAR

Administrative data is

BOTH DEMOGRAPHIC AND FINANCIAL DATA

Releasing information without proper authorization is called a/an

BREACH OF CONFIDENTIALITY

Core Objectives

Basic functions or collection of data that should be completed on a patient's visit or hospitalization.

Explain why electronic forms may not replace paper forms entirely.

Because not all patients have a computer, know how to use a computer, or are willing to complete a computer screen. In addition, some lingering concerns about data privacy may cause some practices to retain paper as a form of data collection.

Registered

Before a patient can be treated at a healthcare setting, they must be _____

Billing for services that are not medically necessary or that did not happen at all is ____________. A. unintentional B. intentional C. fraud D. abuse

Which of the following is NOT a required patient history Birth

Birth

Which of the following is NOT a required patient history?

Birth

Which of the following statements would not be included in the history of present illness?

Blood pressure is 130/84 mmHg, right arm, sitting

Which of the following statements would NOT be included in the history of present illness?

Blood pressure is 130/84, right arm, sitting

Joyce Burke is a healthcare professional working at Greenway Medical. She is responsible for compiling insurance claims and checking them for completion. Which area of the office does Joyce work in Business Office

Business Office

Of the following, which is not an application of an EHR system?

CAPTURE OF INSURANCE POLICY NUMBER

Developed by HL7, this document markup standard specifies the structure and semantics of clinical documents such as discharge summaries, operative reports, etc

CDA

Meaningful use standards require offices to select an EHR that is:

CERTIFIED

Natalie Burns has just arrived for her 1:00 p.m. 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

CHIEF COMPLAINT

A service that processes data into a standardized billing format and checks for inconsistencies or other errors in data.

CLEARINGHOUSE

This EHR database helps manage data that comes from many different sources, ancillary systems in the hospital, or other provider settings as well as from direct entry of structured data by the clinician. What is the name of this database?

CLINICAL DATA REPOSITORY (CDR)

A physician wants an automated system that allows input of signs, symptoms, and results of laboratory tests and provides a list of provisional diagnoses. Which of the following would best meet the needs of the physician?

CLINICAL DECISION SUPPORT SYSTEM

This system provides alerts and reminders to clinicians and can be built into the EHR or can be a stand alone system. What type of system is this?

CLINICAL DECISION SUPPORT SYSTEM

Which clinical information system assists the physician in recording orders and in the decision-making process?

CLINICAL DECISION SUPPORT SYSTEM

There are four broad categories of information system applications. They include research and data analytics systems, administrative information systems, management support systems and

CLINICAL INFORMATION SYSTEMS

What does the "CM" stand for in ICD coding?

CLINICAL MODIFICATION

Which entity administers the Meaningful Use program?

CMS

In order to file a claim to Medicare, a physician's office submits a ___________ form.

CMS-1500

In order to file a claim to medicare, the physicians office has to submit a _______________form

CMS-1500

In order to file a claim to Medicare, a physician's office submits a ___________ form.

CMS-1500. In a physician's office, the required claim form is CMS-1500.

Which of the following is not a vital sign?

COMPLETE BLOOD COUNT (CBC)

The expectation that information shared by an individual with a health care provider during the course of care will be used only for its intended purpose is the definition for

CONFIDENTIALITY

In what form of HIE are data centrally located but logically separated?

CONSOLIDATED

Though the costs of implementing an EHR initially will be high, which record-keeping costs will be less as a direct result of implementing the EHR?

COS OF FOLDERS AND CLIPS TO FILE EACH RECORD

As a part of ABC Hospital, I need to know what role within the organization is responsible for ensuring the organization's compliance with all federal, state, and accrediting body rules and regulations concerning the confidentiality and privacy of health-related information. What role/title am I looking for?

CPO

In a physician's office, procedures and services are converted into numeric form using which coding system?

CPT

Once ICD-10-CM/PCS is implemented, the coding system that will be used to code services and procedures in a physician's office will be _____________.

CPT

The coding system that is used to code services and procedures in a doctors office is called _____

CPT -Fill in

CPT codes are used to capture the face-to-face time spent between a patient and the care provider. A. revenue B. diagnosis C. evaluation and management D. physical exam

Of the following, who will benefit from thoroughly completed paper forms Care providers Receptionists Patients

Care providers Receptionists Patients

evidence-based medicine

Care providers use ____ as a way to support their decisions and diagnoses.

In- network

Care providers who contract with a managed care plan to offer services to members of the managed care plan at a pre negotiated rate.

Of the following, who will benefit from thoroughly completed paper forms?

Care providers, patient's, receptionists

At Heller Memorial Hospital, all patients regardless of the type of patient, emergency department, inpatient, outpatient diagnostics, etc., are registered through the same department. This is known as: Centralized registration

Centralized registration

Centralized registration. Registration that takes place from the same department or area is known as centralized (or central) registration.

This entity was founded in 2004 to certify electronic health records.

Certification Commission for Health Information Technology CCHIT was founded in 2004 to certify EHRs.

Charges begin to accrue once the ____. A. appointment is made B. patient checks in at the reception area C. MA or care provider interacts with patient D. claim has been filed

Is part of the appointment scheduling feature of prime suite.

Chief complaint

A ________ function includes reminders and alerts, diagnostic and therapeutic guidance and links to expert resources?

Clinical Decision Support

Coding practices that are inconsistent with typical practice are known as: A. fraud B. abuse C. illegal activity D. incorrect coding

Common forms of Medicare fraud are listed on the ____________ Network. A. Resipsa Loquitor B. Whistle Blower's C. Qui Tam D. Compliance

review of systems

Comprehensive inventory of patient symptoms such as headaches, vision, heart palpitations, and swelling of joints

A major goal of using an electronic health record is the sharing of important clinical information about a patient. The use of __________ is directly related to this goal?

Continuity of Care Document (CCD)

A major goal of use of an electronic health record is the sharing of important clinical information about a patient. The use of Continuity of Care Documents (CCD) is directly related to this goal.

Continuity of Care Documents (CCD)

A major goal of using an electronic health record is the sharing of important clinical information about a patient. The use of ________________________ is directly related to this goal.

Continuity of Care Documents (CCD)

A major goal of use of an electronic health record is the sharing of important clinical information about a patient. The use of ________________________ is directly related to this goal.

Continuity of Care Documents (CCD). The CCD is used to electronically transmit information about a patient's clinical care between and among caregivers.

Converting narrative diagnoses and procedures into numeric form is known as: A. conversion B. coding C. statistics D. reporting

Discuss the reason(s) care providers have been reluctant to adopt electronic health records.

Cost, staff training, and the time to makes sure everyone understands the process.

Recording a patient's previous or married name might help with

Cross referencing data

Which of the following is a true statement about ICD-10-CM/PCS?

Current coders will need to re-learn how to code

PrimeSUITE allows each user to ___ certain features to their liking

Customize

An advantage of using a screen based data collection tools is that the layout of the information on there can be:

Customized

Which is not true of ACO's?

DATA CAN BE IN STRUCTURED OR UNSTRUCTURED FORM

Betsy is collecting data from a patient, and she asks them for their permanent or current address. The patient responds by asking if she wants their PO Box or physical street address. Where would Betsy find the meaning for the field permanent address? Would it be in the practices's

DATA DICTIONARY

Databases are only as good as the information (data) they contain. What is the central building block that supports communication across business processes as well as improves the data validity and reliability within, across, and outside the enterprise because it ensures that each piece of data can only mean one thing?

DATA DICTIONARY

An important purpose of the DBMS is to maintian the data definitions for all the data elements in the database. It also enforces________?

DATA INTEGRITY AND SECURITY CONSTRAINTS

I will be conducting some analysis of data, but I only need a limited amount of data that are contained in the data warehouse. What system should I utilize?

DATA MART

Database exploration or information discovery is the definition for

DATA MINING

An HIT's ____________________ role includes being aware of security threats and other measures to protect data.

DATA SECURITY

What are the components of an information system?

DATA, PEOPLE, AND PROCESSES AND A COMBINATION OF HARDWARE, SOFTWARE, AND COMMUNICATION TECHNOLOGY

This system is used and geared towards supporting decisions of managers, analysts and the executives of the organization and is sometimes known as the strategic decision support system.

DECISION SUPPORT SYSTEM

Computers can be divided into three categories depending upon their instruction and form of input data that they accept and process. These categories are, analog, hybrid and ___ computers.

DIGITAL

All of the following are the three main non-acute care setting organizations except?

DISABILITY SERVICES

Which of the following is an element of the history of present illness?

DURATION

Accountable Care Organization rely on EHR

Data

Knowing that Jim Smith had a heart attack when he was 53 is an example of:

Data

Which is not true of ACOs?

Data can be in structured or unstructured form

Data dictionary. For consistency, each field is pre-defined using a data dictionary so that only valid entries are entered in the field and so that each staff member interprets the field consistently.

When certain fields are clicked, the most common response to that field may appear. This is known as a Default value.

Default

When certain fields are clicked, the most common response to that field may appear. This is known as a _________ value.

Default. The most common value appears by default so the healthcare professional does not have to scroll through every choice on every patient.

Depending on the terms of a patient's insurance coverage, the balance remaining after insurance has paid may be: A. written off as paid in full. B. removed from the master index. C. sent to collections. D. written off as paid in full or sent to collections.

Prime suite allows you to note discrepancies in the _________field

Details

Unstructured data

Details that cannot be tracked, such as emails and voice recognition technology audio files

Sean Brown is a new care provider and has never before used PrimeSUITE. He is frustrated, and though you have been trying to help him, he is still having difficulty. What would be sound advice to give to Dr. Brown

Direct him to the User's Guide in PrimeSUITE and show him the index, contents, and search features

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?

Discharge Summary

Patty Wolf, a coding supervisor at the local hospital is auditing the quality of ICD-10 coding. She may start by running which type of index to scan for obvious inaccuracies?

Disease Index

Continuity of Care Document (CCD)

Document exchange standard that guides how patient information is shared among providers and healthcare settings

This chapter discussed many advantages of the EHR functionality of ePrescribing. Look at the list below, and select any item that represents a benefit of utilizing ePrescribe capabilities.

Dosing errors are avoided thanks to pop-up alerts. Patient wait time for medicine is reduced. Handwriting and legibility issues are reduced Prescription renewals are made more efficient. Food and drug interactions with prescribed medication are flagged. Quality of care is improved.

Dr. Simmons' office has been notified that they are being audited due to a complaint that was filed by a Medicare patient regarding their billing practices. The audit will be conducted by: A. The Office of Civil Rights B. Centers for Medicare and Medicaid Services C. Internal Revenue Service D. Office of Inspector General

Which piece of information might be included multiple times on a form?

Drug allergies

Notifying a coder that the physician has completed the discharge summary is an example of workflow in the

EDMS

Results management, clinical documentation, closed-loop medication management, clinical decision support, and analytics and reporting are the main components needed for an effective:

EHR

A medical office or other healthcare facility that doesn't have a health information professional on staff may seek expertise in record keeping procedures and legal health record from the __________?

EHR service provider

A medical office or other healthcare facility that does not have a health information professional on staff may seek expertise in record-keeping procedures and the legal health record from the

EHR service provider.

Electronic systems used by nurses and physicians to document assessments and findings are called:

ELECTRONIC POINT-OF-CARE CHARTING

A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in

ELECTRONIC RECORDS

A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in:

ELECTRONIC RECORDS

To help guard against security breaches, emails containing protected health information should be:

ENCRYPTED

The process that encodes textual material, converting it to scrambled data that must be decoded, is call

ENCRYPTION

Why does an ideal EHR system require point-of-care charting?

ENSURES THAT APPROPRIATE DATA ARE COLLECTED

The insurance company sends a statement to the patient explaining charges for services rendered and payment made to the provider for those charges is called the

EOB

Care providers use____________ as a way to support their decisions and diagnoses.

EVIDENCE-BASED MEDICINE

Meaningful use of data requires decision support capability as part of the EHR. This is also known as ___________ because the diagnostic and treatment protocols are based on proven research and best practices.

EVIDENCE-BASED MEDICINE

Mary Smith at ABC Hospital has scheduled a report to be run every Monday listing only the accounts that are past due. What is the name of this type common report that is run from the management information system?

EXCEPTIONS REPORT

The document sent from an insurance company to a subscriber outlining payment decisions is called a/an:

EXPLANATION OF BENEFITS

Free text field

Editing a patients mailing address is accomplished by using ________

The Electronic Health Record (EHR) allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information

Electronic Health Record (EHR)

The ___________ allows for the exchange of information among care givers, insurance companies and other when there is a need for information

Electronic Health Record (EHR)

The ____________ allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information.

Electronic Health Record (EHR)

The ____________ allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information.

Electronic Health Record (EHR) Having all medical information stored in an electronic record makes sharing that information quick, easy, and accurate.

credentialed or degreed health information professional

Eligible providers taking advantage of HITECH funds must have a ________ or _______ ________ ______ _______on staff.

Of the following, which is an accurate statement?

Eligible providers taking advantage of HITECH funds must have a credentialed or degreed health information professional on staff.

Of the following, which is an accurate statement?

Eligible providers taking advantage of HITECH funds must have a credentialed or degreed health information professional staff.

If a hospital uses information gathered through their EHRs to justify the purchase state of the art equipment to improve patient care, they are:

Engaging in meaningful use.

An insurance claim may be denied if the receptionist fails to

Enter all data correctly

Which of the following is a goal of HIPPA

Establish standards for keeping of health information

Expected methods of payment are discussed when a patient: A. checks in. B. is seen by the provider. C. is discharged. D. makes an appointment

The list of how much is charged per service by CPT code is the definition for which term?

FEE SCHEDULE

You have just data entered information into an online form. The box in which you entered the information is known as a/an:

FIELD

Mary Bontrager has come to the physicians office today for a scheduled appointment and while registering her, the registration clerk seen a dialogue box open that stated, "Sensitive information contained in chart". This reminder is known as a ___________.

FLAG

Within the EHR is a tool created to serve as a reminder to the staff and care providers that has a specific meaning. What is the name of this electronic tool?

FLAG

To avoid negative consequences, a compliance plan should be ____ in every hospital and medical office.

FOLLOWED

Billing for services that are not medically necessary or that did not happen at all is

FRAUD

A patient's vital signs can be easily viewed via prime suites ___________screen.

Face sheet

A patient's vital signs are entered via PrimeSUITE's Facesheet screen.

Facesheet

The patient's _________ history can help predict a future health condition.

Family

The ________________________ is published by the federal government and includes all actions taken by any government entity on a given date.

Federal Register The Federal Register is published daily by the U.S. government and details all actions taken that day by the government.

An on-screen item of data is known as a:

Field

Jane Howard often misses appointments; an alert is set to appear on her record; this alert is known as a/an_______ in PrimeSUITE

Flag

According to the text, which of the following is a way to make the transition to EHRs easier?

Following the advice and suggestions of the EHR service provider's installation team.

CMS-1500

Form used to submit insurance claims in a hospital setting

UB-04

Form used to submit insurance claims in a hospital setting

Editing a patient's mailing address is accomplished by using

Free text fields

Groups of doctors and other healthcare providers and facilities who voluntarily form a partnership that results in high quality, coordinated healthcare is known as a/an: A. Accountable Healthcare Organization B. Managed care plan C. Fee-for-service plan D. Accountable Care Organization

The coding system used in illustrating the tangible items such as supplies is:

HCPCS level 2

Which of the following would be considered a covered entity?

HEALTH CARE PROVIDER

The acronym HIE stands for:

HEALTH INFORMATION EXCHANGE

The body of knowledge and practice that ensures the availability of health information to facilitate real-time health care delivery and critical health-related decision-making for multiple purposes across diverse organizations, settings and disciplines is the definition for

HEALTH INFORMATION MANAGEMENT

When a document is amended or changed in an EHR, the original documentation is:

HIDDEN FROM VIEW

Why is it important that health information managers and health informatics managers work closely together?

HIM typically collects the data from patient records, while informatics mines, analyzes, and works with the data.

Administrative data are used to satisfy _________requirements

HIPAA

true

HIPAA protects the patient's info whether it be paper, computer, or oral.

notice of privacy practices

HIPAA requires that patients are notified after rights, in writing, of ways in which their health information will be used and released to outside entities. This is known as

Incentives are being offered to EHR adopters through ____ legislation.

HITECH

Incentives are being offered to EHR adopters through _________ legislation.

HITECH

The use of e-prescribing is part of the requirements for:

HITECH

The use of ePrescribing is part of the requirements for

HITECH

The use of ePrescribing is part of the requirements for:

HITECH

Which act stated that a qualified EHR "includes patient demographic and clinical health information, such as medical hx, problem lists; and has the capacity to provide clinical decision support, support CPOE, capture and query information relevant to health care quality, and exchange electronic health information with and integrate such information from other sources?"

HITECH

true

HITECH regulations require that all information releases are accounted for

All

HITECH regulations require that information releases are accounted for

The use of ePrescribing is part of the requirements for

HITECH.

What is the name of the SDO (standards developing organization) that provides for us the comprehensive standards needed for EHR communications?

HL7

What is the name of the SDO that allows different software packages to interface with one another?

HL7

Which SDO develops messaging, data content, and document standards to support the exchange of clinical information?

HL7

Clinical Document Architecture (CDA)

HL7 standard that outlines the format of clinical documentation, such as reports and discharge summaries

Which of the following systems would be used to manage productivity?

HUMAN RESOURCE SYSTEM

Unintended consequences from using EHR technology are primarily due to issues with:

HUMAN USERS

devices such as laptops, PDS, and desktop computers that are at risk for theft are called

Hardware

A credentialing requirement is:

Having malpratice insurance.

The acronym HIE stands for:

Health Information Exchange

Clinical Documentation Architecture (CDA) and Quality Reporting Documentation Architecture (QRDA) are both specific data standards of the broader _________ standards.

Health Level Seven (HL7)

Clinical Documentation Architecture (CDA) and Quality Reporting Documentation Architecture (QRDA) are both specific data standards of the broader _________ standards.

Health Level Seven (HL7). HL7 is the software standards most widely used in healthcare. The CDA and QRDA are more specific standards recognized by HL7.

technological

Health informatics is basically the ____ part of managing health information.

Which of the following is an independent nonprofit organization with a mission to lead health care transformation through the effective use of health information technology?

Healthcare Information and Management System Society (HIMSS)

Reporting cases of fraud and abuse must be done to which bank?

Healthcare Integrity and Protection Data Bank (HIPDB)

Of the menu items listed at the top of the screen, which will be used to determine what the shortcut F6 means in PrimeSUITE Help

Help

The feature in PrimeSUITE which guides the user about how specific functions or applications work is known as: Help

Help

Of the following, which does not need to be sent to an insurance company on the CMS-1500 claim form? History of present illness

History of present illness

Permanently

How long should a facility's Master Patient Index be kept

as of October 1, 2015 the coding system to code diagnosis in any healthcare setting is...

ICD-10

As of October 1, 2014, the coding system used to code diagnoses in any healthcare setting is:

ICD-10-CM

The required code set for documenting diagnoses on all patients in any care setting is known as: ICD-10-CM

ICD-10-CM

As of October 1, 2015, the coding system used to code diagnoses in any healthcare setting is

ICD-10-CM.

The required code set for documenting diagnoses on all patients in any care setting is known as

ICD-10-CM.

The required code set for documenting diagnoses on all patients in any care setting is known as:

ICD-10-CM. CPT codes are used to code procedures, HCPCS are codes for tangible items such as crutches, canes, and transport, ICD-10-PCS is used to code procedures.

ICD-10-CM/PCS is being implemented because: A. the American Medical Association has requested it. B. ICD-9-CM no longer meets the needs of healthcare organizations. C. it is already in use in Canada. D. ICD-9-CM is out of print.

ICD-10-CM/PCS is being implemented because:

ICD-9-CM no longer meets the needs of healthcare organizations.

ICD-10-CM/PCS was implemented because

ICD-9-CM no longer meets the needs of healthcare organizations.

In which phase of the SDLC are trial runs of the new system conducted, backup and disaster recovery procedures developed, and training of end users performed?

IMPLEMENTATION

The purpose of a physician query is to:

IMPROVE DOCUMENTATION

The accountability framework and decision rights to achieve enterprise information management (EIM). EIM is defined as the infrastructure and processes that ensure information is trustworthy and actionable." This is the definition for

INFORMATION GOVERNANCE

Information resource management (IRM) addresses information in what format?

INFORMATION STORED IN ANY FORMAT

Revenue Cycle Management includes all of the following except:

INSURANCE VERIFICATION

According to AHIMA, what is the number one item that is most important about the EHR documentation? Is it data

INTEGRITY

The ability of one computer system to exchange data with another computer system is the definition for

INTEROPERABILITY

_________ is not easily attained when using a manual record system.

INTEROPERABILITY

Many offices use an internal, secure environment to communicate important information to their employees. This is known as a/an?

INTRANET

Patient check in is

Important for efficient patient tracking

In PrimeSUITE, a red "X" on a Superbill summary indicates: A. an absent diagnosis. B. an invalid code assignment. C. a charge line will not be posted. D. a charge is ready.

Medical record number

In a hospitals health information department, patients records are most often filed by ______________

In a physician's office, procedures and services are converted into numeric form using which coding system? A. ICD-9-CM B. HCPCS C. CPT D. ICD-10-CM/PCS

In many managed care plans, patients are responsible for paying a portion of the charges at the time services are rendered. This is known as the: A. deductible B. coinsurance C. co-pay D. balance

library

In terms of computer software,a comprehensive listing of related entities to choose from such as ICD-10 codes

All of these

In the event of a breach, who may be held responsible

What were the physical exam findings from the physical exam performed on Patty?

In the lungs there are rales and rhonchi on ausultation -Fill in

The health information manager and the Information Technology Manager/Officer work closely to ensure a fully operational, secure electronic health record that meets the needs of all users within the facility

Information Technology Manager/Officer

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

Information Technology Manager/Officer

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

Information Technology Manager/Officer. The health information management and information technology departments are closely related. The HIM managers ensure the information collected satisfies legal, accreditation, and patient care-related data. The IT managers ensure the security, interoperability, and performance of electronic systems.

Subscriber

Information such as policy holder name and insurance plan name appear in the ________section of claim form

Administrative data

Information, such as a patient's insurance information, marital status, employer

The _____ defined the eight core functions if the EHR

Institute of Medicine

Instant access to information is available through a public series of networks. What is this network commonly called?

Internet

Instant access to information is available through a public series of networks. What is this network commonly known as:______?

Internet -Fill in

Which of the following is an acceptable way of gathering a patient's history Interview

Interview

Which of the following is an acceptable way of gathering a patient's history?

Interview

Many offices use an internal, secure environment to communicate important information to their employees. This is known as a/an?

Intranet

Which of the following is a true statement about using practice management (PM) software for an office's claims management process?

It allows for more efficient tracking and reporting of daily transactions.

Offsite

It is critical that backup files be stored

Which of the following statements is true about a personal health record (PHR)?

It is maintained by the patient (or legal guardian).

Which of the following statements is true about a personal health records (PHR)?

It is maintained by the patient or legal guardian

Dr. Lewis's office collects patients' co-pays at the time of arrival; Dr. Mbadu's office collects the co-pay as the patient is leaving the visit. Is one method more advisable than the other? Explain your answer.

It may be more advisable to collect the co-pay prior to care being given because if the patient is not able to pay the co-pay at that time, the appointment can be rescheduled. Once the services are given, if the patient says they do not have the money, then nothing can be done at that point.

Of the following, which factor contributes to the access rights allowed a user?

JOB DESCRIPTION

PrimeSUITE's reports can be used to:

Justify the cost of new equipment perform quality check track care provider data

You are designing a registration form. The patient's employer is a data field. What related data might you also collect regarding the patient's employer and why?

Key pieces of data are name of employer, address of employer, phone number, position within the company, and how long the patient has been with the company.

All of the following are external forces that affect HIM except:

LACK OF HEALTH CARE ORGANIZATIONS

Documentation standards can be found in four major sources. Healthcare organizations must be given this by government entities such as the state or county in which they are located and must maintain this as long as care is provided in the facility. This definition is for what standard?

LICENSURE

LaRhonda Howard is seen today by Dr. Bilkins for a chief complaint of recurrent abdominal pain and loss of appetite. Robert Drew is seen today by Dr. Bilkins for a chief complaint of follow-up for his poison ivy, which he was treated for last week. Which of these patients is likely to have a more extensive physical exam?

LaRhonda Howard

A new staff member in your office has a question about scanning. How would you explain the process to her?

Lay the document on the screen, follow the prompts, and merge the digital copy into the proper patient's health record.

These possible values are derived from a Library within the system.

Library

You are about to enter the marital status of a patient, and upon clicking in that field, the following appears: ___ Single ___ Married ___ Separated ___ Divorced ___ Widow/Widowed These possible values are derived from a _____________ within the system.

Library. A collection of possible responses for each field is known as a library.

data dictionary

List of correct definitions for a facility's unique terms and jargon

Computers and devices that physically close together are connected by a ____?

Local Area Network (LAN)

Computers and devices that are physically close together are connected by a

Local Area Network.

Care providers who contract with insurance carriers typically agree to a __ rate of reimbursement for those services

Lower

A computer architecture built with a single central processing unit to which dumb terminals and/or personal computers are connected is called a/an

MAINFRAME

Which of the following computer information architectures uses a single large computer to process data received from dumb terminals into which data are entered?

MAINFRAME

The actual claim process begins when the patient

MAKES THE APPOINTMENT

The form of insurance that monitors patients, care, and performance to ensure quality is the definition for

MANAGED CARE PLAN

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

MARITAL STATUS

Datasets that provide structure and are the building blocks for parts of the health record are known as __________ files.

MASTER

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 that hospital before, or whether you must register them for the first time?

MASTER PATIENT INDEX

Which requirement listed below is part of the requirements of the HITECH Act which is meant to increase the use of an EHR through monetary incentives provided the EHR is used in a meaningful way to improve patient care and is implemented in core objective stages?

MEANINGFUL USE

In the acute care setting and using the MPI, what one specific piece of data allows a health care employee to locate the corresponding health (medical) record faster and more accurately for each patient for record requests? Is it the

MEDICAL (HEALTH) RECORD NUMBER

In the Medicare Core Objectives, Stage 1 of the CPOE standards only addressed:

MEDICATION ORDERS

With the closed-loop medication management system, what is the most difficult task to complete?

MEDICATION RECONCILIATION

The more voice recognition software is used, the:

MORE IT LEARNS VOICE INFLECTIONS

Anna Jacobs presented to the ER of OTC Hospital three times in the past year. What tool will the staff at OTC Hospital use to locate Anna's record?

MPI

What are the two key pieces of information that should be on all forms in a patient's EHR?

MRN AND NAME

A facility's collection of patient data might be used to satisfy _________requirements

Meaningful use

Certified

Meaningful use standards require offices to select an EHR that is

Which of the following is not a care provider Medical Assistant

Medical Assistant

In the CPOE standard, Stage 1 only addressed :

Medication orders

Clinical decision support

Method of accessing current treatment options for a disease, through electronic or remote methods

You are a healthcare professional at Greensburg Medical Center and you have just shown a patient, Mrs. Clark to the check out desk where the billing coordinator has just taken the encounter form (superbill) for the visit. Dr. Daniels comes to the window and states that Mrs. Clark left the exam room before receiving her flu shot. What do you do?

Mrs. Clark will be taken back to the exam room, will be given the shot by the healthcare professional, who will document it in Mrs. Clark's record, and will update the encounter form to reflect the charges for the flu shot, at which point Mrs. Clark will return to the check-out desk

You are a healthcare professional at Greensburg Medical Center and you have just shown a patient, Mrs. Clark, to the check-out desk, where the billing coordinator had just taken the encounter form (superbill) 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

Which of the following typically would not be collected as part of the past surgical history?

NAME OF THE ANETESIOLOGIST

Every form used should include in the title the ______________ so that the forms's use is obvious.

NAME OF THE FORM

Which generation of programming language is used widely to develop expert systems that help physicians manage patient care, telemedicine, teleradiography, and other e-health and telemedicine activities?

NATURAL LANGUAGE/ARTIFICIAL INTELLIGENCE (AI)

Only services deemed medically _______ can be billed to insurance.

NECESSARY

Which of the following connects computers together in a way that allows for the sharing of information resources?

NETWORK

Point-of-care charting systems in hospitals today are used primarily by:

NURSES

What information should you see on all forms in a patient chart Name DOB Medical record number

Name DOB Medical record number

What information should you see on all forms in a patient's chart

Name , DOB , medical record number

"A set of standards, services, and policies that enable the secure exchange of health information over the Internet" is known as: National Health Information Network

National Health Information Network

set of standards, services, and policies that enable the secure exchange of health information over the Internet" is known as:

National Health Information Network

"A set of standards, services, and policies that enable the secure exchange of health information over the Internet" is known as:

National Health Information Network The National Health Information Network provides guidance on securely exchanging information over the Internet.

A unique identifier that is required on claim forms and identifies the care provider or group practice submitting the claim is the:

National Provider Identifier number

A unique identifier that is required on claim forms and identifies the care provider or group practice submitting the claim is the: National Provider Identifier number

National Provider Identifier number

A unique identifier that is required on claim forms and identifies the care provider or group practice submitting the claim is the:

National Provider Identifier number The social security number of the care provider is not used, nor is his/her license number. Care providers do not have policy numbers, except for their own, personal insurance plan that covers themselves and their spouse or family.

Nick Malone underwent an appendectomy by Dr. Lopez on September 5. Dr. Lopez documented appendicitis as Mr. Malone's diagnosis. The diagnosis was documented ______________________. A. to show medical necessity B. to avoid fraud charges C. to prove why he missed work D. to prove what procedure was done

Information gathered during the provider's physical exam would appear in the _____________ section of a SOAP note.

OBJECTIVE

It is critical that backup files for the health care organization be stored:

OFF SITE

Mercy Medical Hospital has recently purchased a new Practice Management software program for their physician clinics. They are needing to set up information libraries within the software program. Who is usually responsible for setting up these libraries?

OFFICE MANAGER

The essential elements of a Corporate Compliance Program are defined by

OIG

David Allen Coe has visited OTC Hospital many times. His dates of service are these: Jan 8, 2012-appendicitis-admitted; May 14, 2012-ER for asthma attack; July 21, 2013-urgent care-virus; August 4, 2013-inpatient for pneumonia; & December 16, 2014-ER, sprained ankle. How many times will David's name and demographic information be entered into the MPI of OTC Hospital?

ONE

Health care facilities have ________ year(s) after adoption of an EHR to prove meaningful use.

ONE (1)

A facility needs to make sure that the information on their intranet does not become:

OUTDATED

The results of a patient's rapid strep test would be found in what area of a SOAP note?

Objective

results of a patient's rapid strep test would be found in what area of a SOAP note?

Objective

Dr. Clark has just documented his findings of a physical exam performed on Patti Wolfe. She was seen today for productive cough. These findings are considered what kind of findings, as they relate to the SOAP note?

Objective findings

____________is part of a patient's administrative information found on a registration form

Occupation

Job description

Of the following, which factor contributes to the access rights allowed a user

Of the following, which is not a reason that the United States did not implement ICD-10 at the time other countries did? A. costly to convert from one coding system to the other B. decision whether ICD-10 or CPT would be used to code diagnoses C. increased training needs D. unknown whether ICD-10 would meet the needs of the United States

Of the following, which would be a library used in the accounts receivable functions of a practice management system? A. insurance company names B. patient names C. patient addresses D. patient telephone numbers

Of the following, which would be included on a remittance advice or explanation of benefits? A. total charges for a patient's account B. subscriber's address C. effective date of insurance D. employer's information

Some managed care plans encourage the use of clinical decision support (CDS) functionality by: _______?

Offering monetary incentives to care providers who utilize CBS or CVS

In a physician's practice, Office Administrator may be the title of the person who is responsible for the overall administrative management of the practice

Office Administrator

In a physician's practice, ________________ may be the title of the person who is responsible for the overall administrative management of the practice.

Office Administrator

In a physician's practice, ________________ may be the title of the person who is responsible for the overall administrative management of the practice.

Office Administrator An office administrator is tasked with keeping the entire office running smoothly.

Dr. Simmons' office has been notified that they are being audited due to a complaint that was filed by a Medicare patient regarding their billing practices. The audit will be conducted by:

Office of Inspector General

Dr. Simmons office has been notified that they are being audited due to a complaint that was filed by a medicare patient regarding their billing practices. The audit will be conducted by....

Office of the Inspector General (OIG)

Anna Jacobs presented to the ER of County Hospital three times in the past year. She will appear in County's MPI:

Once

both cost and errors.

One benefit of accessing the EHR through mobile devices is a reduction in:

Only services deemed medically ________ can be billed to insurance. A. necessary B. progressive C. restorative D. useful

Who is responsible for maintaining a personal health record?

PATIENT

The clinical information system includes systems that support

PATIENT CARE

When documenting in the patient record, using templates makes it easier for care providers to focus on their first priority, which is:

PATIENT CARE

All of the following are types of administrative information systems except:

PATIENT REGISTRATION SYSTEMS

What is the objective of Patient Centered Medical Homes (PCMH)?

PCMH is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand.

Ozarks Technical Community Hospital receives a report each morning listing all of the admissions from the day before. This is an example of what type of report?

PERIODIC SCHEDULE

How long should a facility's MPI be kept?

PERMANENTLY

This tool is a type of chart that helps the HIM professional with software selection by helping them evaluate the tasks, activity sequence and time to complete the tasks. This tool is known as the ____ chart.

PERT

The primary user of computerized provider order entry is:

PHYSICIAN

Notes about a prescription ordered for a patient would appear in the ______ section of a SOAP note.

PLAN

Which of the following illustrates clinical information collected through an EHR?

PLAN OF CARE

As the HIM project manager for software selection, you know you must complete what step first in the software selection process?

PLANNING

The first phase of the SDLC (system development life cycle) is the ________ phase.

PLANNING

Meaningful use regulations require the keeping of an up-to-date:

PROBLEM LIST

The biggest complaint physicians have with using an EHR already installed relates to

PRODUCTIVITY

The primary roles of the HIM professional in the future are focused on five main funtional areas of health information. Thise five main functional areas have a common theme of ____ and ____ health information.

PROTECTING, MANAGING

The internet is _______ and the intranet is _______________.

PUBLIC, PRIVATE

Which of the following statements is true about a paper record?

Paper records are often illegible.

Who is responsible for maintaining a personal health record?

Patient

Using templates makes it easier for care providers to focus on their first priority which is

Patient Care

Greensburg Medical Center provides each patient with written documentation that details the signs, symptoms, current treatment options, and other pertinent information about their condition(s). This satisfies which menu objective?

Patient Education

Important for efficient patient tracking

Patient check in is__________________

At each visit

Patient demographic information should be verified

vital signs

Patient information such as blood pressure and respiratory rate

medical history

Patient information that includes immunization and allergies

Social History

Patient information that includes information such as frequency of drinking and smoking

Surgical History

Patient information that includes past procedures and who performed the procedures

family history

Patient information that includes possibly inherited condition

In a physician's practice, the index of all patients seen in that practice is most commonly known as the:

Patient list. In a physician's practice, this list of patients is more frequently referred to as the patient list than the master patient index.

2015

Penalties for facilities not adopting electronic health records will begin in ____.

master patient index

Permanent roster of all patient's ever seen in a healthcare setting

How long should a facility's master patient index be kept?

Permanently

The MPI and patient list should be kept: Permanently

Permanently

The MPI and patient list should be kept:

Permanently. The MPI or patient list should be kept permanently since that is the record of every patient who has received care at the facility.

Dr. Brown, a radiologist is able to view x-ray images from home rather than having to go into the hospital to do so. What kind of computer technology allows Dr. Brown to do that?

Picture Archiving and Communication Systems

Dr. Brown, a radiologist is able to view x-ray images from home rather than go into the hospital to do so. What kind of computer technology allows Dr. Brown to do that ________?

Picture Archiving and Communication Systems (PACS) - Fill in

Plan

PrimeSUITE is what kind of computer software Practice Management and Electronic Health Record

Practice Management and Electronic Health Record

Which of the following requires completion of a competency exam, but does not result in certification?

Practice Workflow & Information Management Redesign Specialist

Which of the following requires completion of a competency exam, but does not result in certification? Practice Workflow & Information Management Redesign Specialist

Practice Workflow & Information Management Redesign Specialist

Which of the following requires completion of a competency exam, but does not result in certification?

Practice Workflow & Information Management Redesign Specialist. While there is no certification for it, health professionals must pass a competency exam to be known as a Practice Workflow & Information Management Redesign Specialist.

Medical providers are able to share information between/among one another if they use an electronic health record in their office. In PrimeSUITE this application is known as PrimeEXCHANGE

PrimeEXCHANGE

The documentation of a patient's office visit is often referred to as a/an: Progress note

Progress note

Which of the following is an acceptable way of gathering a patient's history?

Provider asks the patient questions

1. The internet is ___ & and itranet is _____

Public, & Private

One of the most important aspects of information resource managment (IRM) is ensuring data

QUALITY

Common forms of Medicare fraud are listed on the ____________ Network.

Qui Tam

One of the common help features is

Quick start guide

What does the abbreviation R-ADT mean?

REGISTRATION, ADMISSION, DISCHARGE TRANSFER

You are reviewing a report which shows the patients born at Memorial Hospital from January 1, 2011 through December 31, 2011. The report is sorted by date and includes patient name, name of mother, time of birth, and name of obstetrician. Which type of report are you reviewing?

REGISTRY

There are three popular types of databases. Which database type stores data in predefined tables that contain rows and columns similar to a spreadsheet?

RELATIONAL

An insurance company submits payment to a medical practice, along with a document that details the patients and the accounts for which payment is made. This document is called the

REMITTANCE ADVICE

The hospital needs to know how much Medicare paid on a claim so they can bill the secondary insurance. What documentation should they refer to?

REMITTANCE ADVICE

__________ encompasses the identification, management, and control of untoward events.

RISK MANAGEMENT

chief complaint

Reason for a patient's appointment; may determine the length of an exam visit

technology

Recent advances in healthcare rely increasingly on:

Master Patient Index

Record of all patients seen in a hospital setting

Which of the following passwords would be considered the most secure?

Record**58nonprofit organization with a mission to lead health care transformation through the effective use of health information technology?

Cross referencing data

Recording a patients previous or married name might help with

A Registered Health Information Administrator (RHIA) professional would most likely hold one of the following positions: cancer registrar, privacy officer, software analyst, compliance officer.

Registered Health Information Administrator (RHIA)

A ______________________ professional would most likely hold one of the following positions: cancer registrar, privacy officer, software analyst, compliance officer.

Registered Health Information Administrator (RHIA)

A ______________________ professional would most likely hold one of the following positions: cancer registrar, privacy officer, software analyst, compliance officer.

Registered Health Information Administrator (RHIA) Health Information professionals have the education and background necessary to hold any of the positions listed.

The hospital equivalent to practice management software used in the physician's practice is known as:

Registration, Admission, Discharge, Transfer System

The hospital equivalent to practice management software used in the physician's practice is known as: Registration, Admission, Discharge, Transfer System

Registration, Admission, Discharge, Transfer System

The hospital equivalent to practice management software used in the physician's practice is known as:

Registration, Admission, Discharge, Transfer System In the hospital setting, patients need to be registered or admitted (for an inpatient stay), discharged when they have vacated the bed, and transferred if they are moved from one bed to another.

The steps listed below are carried out by which staff during an office visit? Patient Arrives for visit > Update Patient Information > Check In and Collect Co-pay > Start Patient Tracking Registration/Front-Desk

Registration/Front-Desk

A report that shows that a patient is born in Michigan, this is an example of a

Registry

You are reviewing a report which shows the patients born at Memorial Hospital from January 1, 2012 through December 31, 2012. The report is sorted by date and includes patient name, name of mother, time of birth, and name of obstetrician. Which type of report are you reviewing?

Registry

Breach of confidentiality

Releasing information without proper authorization

An insurance company submits payment to a medical practice, along with a document that details the patients and accounts for which payment is made. This document is called the:

Remittance advice

Review of Systems (ROS)

Craig is in the office of Dr. Hammer for his annual physical. Dr. Hammer asks Craig a series of questions such as do you have frequent headaches? do you have frequency of urination? Do you have difficulty sleeping? These questions are part of....

Review of Systems (ROS)

Kelly is being seen by her physician today, and he is asking her if she's had any increase in or unusual headaches since her last visit, whether she has any blurred vision, and whether she has seen her eye doctor in the past year. The answers to these and other questions are documented in what part of the health record?

Review of Systems (ROS)

The protection measures and tools for safeguarding information and information systems is the definition for

SECURITY

The most widely recognized nomenclature in health care is

SNOMED CT

To provide a controlled vocabulary for coding the contents of the patient record and for facilitating the development of computer-based patient records is the function of what classification system?

SNOMED CT

Per the IOM, all of the following are core functions of the EHR except

SOURCE-ORIENTED HEALTH RECORD

What is the purpose of computer databases?

STORE AND RETRIEVE DATA

Drop-down lists, check boxes, radio buttons, and other forms of controlled data entry is used in what type of data entry?

STRUCTURED

What step(s) should be taken to ensure a scanned image is properly filed within a patient's health record?

Scanned images must first be verified to ensure they are made a part of the correct patient's record as well as the correct encounter for that patient.

A hard-copy document is attached to a patient's electronic chart by:

Scanning

Virginia Reed called Greensburg Medical Center to make an appointment for her annual physical exam. This step in the process is called: Scheduling

Scheduling

Virginia Reed called Greensburg Medical Center to make an appointment for her annual physical exam. This step in the process is called:

Scheduling. Registration may be part of scheduling, but is considered a separate function.

Which of the following is not a type of medical insurance Self-pay from patient

Self-pay from patient

Which of the following would include a patient's exercise regimen Social history

Social history

Which of the following would include the patient's frequency of alcohol consumption?

Social history

What is practice management software?

Software specifically designed for use in a medical office; records and saves patient information and flow. Practice management software is specially-designed software for use in a medical office

Healthcare systems administrator

Staff member whose responsibilities include management of a facilities IT functions

PrimeSUITE's Referring Provider report is an example of a _______ report.

Standard

A report run on demand is created when it is needed.

Standart Report - run to show how much pt owes its called pt balance report.

You are the office manager of a family practice that is still using a paper record. How would you argue the point for adoption of an electronic health record to the managing care providers in that practice?

Stress the less time it would take to find patient information or time it takes to file families together. The EHR will make the office run smoother and make documenting more specific and easier to send referrals.

Alison Holt just received a copy of her Clinical Visit Summary from the visit to her primary care provider earlier in the day. She is reading that her symptoms were present for the past four days, and that she did not get any relief from Motrin. To which section of the SOAP note does this information pertain?

Subjective

Information such as a policyholders name and insurance plan name appear in the ________section of a claim form

Subscriber

Jane Smith is the manager of the HIM department at OTC hospital. The facility has been utilizing an EHR for a year now, and one of the features Jane loves is the fact she can create a "to-do" list to not only herself but her staff to complete scheduled work in a timely fashion. The ability to create an electronic "to-do" list is known as a/an

TASK LIST

Health informatics is basically the_______ part of managing health information.

TECHNOLOGICAL

Recent advances in health care rely increasingly on

TECHNOLOGY

This new, emerging technology allows the physician to to examine and treat a patient without either party traveling. What is the name of this new technology?

TELEMATICS

Videoconferencing and remote vital sign monitoring are part of

TELEMEDICINE

What is the difference between the executive information systems and the decision support system?

THE EXECUTIVE INFORMATION SYSTEM IS DESIGNED TO BE UDED BY HIGH-LEVEL MANAGEMENT

Evaluate the following statement: Inpatient information systems are exactly the same as ambulatory information systems.

THIS IS A FALSE STATEMENT. THEY HAVE MANY COMMON FUNCTIONS, B UT EACH SYSTEM HAS UNIQUE FUNCTIONS AS WELL

Which of the following is an example of when an executive decision support system should be used?

TO IDENTIFY A NEW SERVICE FOR THE HOSPITAL TO IMPLEMENT

The HIM department director receives daily reports on the number of new admissions to and discharges from the hospital. Which type of information system is being used to produce this information?

TRANSACTION-PROCESSING SYSTEM

A person hired to manually record a physician's dictated word is known as a:

TRANSCRIPTIONIST

*Health informatics is basically the part of managing ___________ health information.

Technological

Explain why a personal health record is not a legal document.

The PHR is maintained in a secure and private environment, with the individual determining rights of access. The PHR does not replace the legal record of any provider.

The ________ is usually the person to set up information libraries within Practice Management software programs. A. care provider B. healthcare professional C. medical assistant D. office manager

The actual claim process begins when the patient: A. is discharged B. makes the appointment C. is seen by the care provider D. pays the bill

The amount charged for each service provided in a medical practice is known as a/an: A. chargemaster B. fee schedule C. ledger D. day sheet

The amount of a patient's co-pay may vary by: A. care provider. B. insurance plan. C. office location. D. visit type.

What is the CMS-1500 form?

The billing form used for physician's office insurance claims. The CMS-1500 form is used to bill insurance claims for a physician's office.

The coding system used in illustrating the tangible items such as supplies is: A. ICD-9-CM B. HCPCS level 2 C. CPT D. ICD-10-CM/PCS

The information contained in the encounter form is eventually transferred to the ________ form for submission. A. claim B. encounter form (Superbill) C. insurance D. registration

The last step in the medical billing cycle is: A. Review coding compliance B. pre-register patients C. follow-up payments and collections D. establish financial responsibility

Increase the implementation of EHR systems

The mission of CCHIT is to

Explain how EHR software, ensures the correction or amendment to an electronic record is made without jeopardizing the integrity of the record.

The original version remains in the system and is retrievable at any time. It is never truly deleted.

In a physician's office, patient data collection begins when:

The patient calls to make an appointment.

What are the two pieces of data that should be on every page of a paper record, even on the front and the back, if a two-sided document in order to ensure each form is on the correct patient's record?

The patient's full name and his/her chart (medical record) number.

Of the following, which is an advantage of adopting an electronic health record The potential for interoperability with other computerized systems within the practice or hospital.

The potential for interoperability with other computerized systems within the practice or hospital.

The primary person covered by an insurance plan is the: A. patient B. prescriber C. subscriber D. provider

Credentialing

The process of ensuring a care provider has the proper qualifications.

Health information exchange

The sharing of health information among various entities, using standardized and secure processes.

Secure

The sharing of health information must be done in a environment

The source document for completing the actual insurance claim form is the: A. medical record B. CMS-1500 C. UB-04 D. encounter form

The type of insurance plan that promotes quality, cost-effective healthcare by monitoring patients, encouraging preventive care, and requiring performance measures of physicians is known as: A. Medicare Part C B. managed care C. fee-for-service D. consumer driven

Mrs. Lam was sent from her doctor's office to the outpatient laboratory for a urinalysis. Her insurance company denied the claim stating that the procedure was not necessary. The healthcare professional reviewed the claim and saw that a urinalysis was ordered, and the diagnosis listed on the encounter form was upper respiratory infection. Why was this claim denied?

This claim was denied because a diagnosis of upper respiratory infection would not show medical necessity for a lab test to be run on a urine sample.

To avoid negative consequences, a compliance plan should be ____ in every hospital and medical office. A. discussed B. followed C. used as a guide D. written

To check if a claim has been paid, which menu will the healthcare professional look at? A. Accounts payable B. Accounts receivable C. Claims processing D. Claim updates

Explain why each page of a multipage form should include the patient's name and the medical record number.

To guard against mixing up the records of patients with the same or similar names and to guard against documentation errors in general.

Encrypted

To help guard against security breaches, emails containing protected health information should be

Which type of data is also called narrative or free text data?

UNSTRUCTURED

Might be

Under a care providers order, medical assistants and nurses allowed to send an ePrescription or call in a refill prescription to a pharmacy

Which of the following functions is carried out during the check-in steps Update patient information

Update patient information

Meaningful use

Use of health information in an effective and efficient manner to improve patient care

What does VPN stand for?

VIRTUAL PRIVATE NETWORK

What type of standard establishes common definitions for medical terms?

VOCABULARY

Currently, participation in the Physician Quality Reporting Initiative is:

VOLUNTARY

An advantage of EHRs is that the patients are now able to _____ about procedures they are undergo.

View videos.

Virtual Private Network

What does VPN stand for?

Virtual Private Network

There must be a/an _____________ available in order for providers to use portable devices to access health information.

WIRELESS CONNECTION

Virtual Private Network

What does VPN stand for?

What does the "CM" stand for in ICD coding? A. Care management B. Clinical modification C. Code management D. Coding methodology

Primary physician

What is not an example of demographic data

Hidden

When a document is amended or changed in an EHR, the original documentation is

Which is not true of ACOs? A. There are currently two models: Medicare Shared Savings and Advance Payment Model. B. Sharing of patient information through an EHR is necessary C. Data can be in structured or unstructured form D. Participation in an ACO is voluntary

Which of the following is a true statement about ICD-10-CM/PCS? A. It will only be used in physicians' office settings. B. Current coders will need to re-learn how to code. C. Healthcare facilities will have the choice to either continue to use ICD-9-CM or convert to ICD-10-PCS. D. The adoption of ICD-10-CM/PCS was endorsed by the American Medical Association in 1990.

Which of the following is a true statement about using practice management software for an office's claims management process? A. it ensures a more accurate electronic health record B. insurance verification is completed automatically C. it is required by Medicare D. it allows for more efficient tracking and reporting of daily transactions

Which of the following is not part of a paper encounter form (Superbill)? A. name of the medical practice B. CPT codes for procedures C. the medical history D. ICD-9-CM diagnosis codes

Which of the following is true of the advance payment ACO model? A. It is based on fee-for-service. B. It is an incentive model. C. It is the largest Accountable Care Organization. D. It requires participation by hospitals and medical vendors.

Patient care organizations, Payers, Research agencies

Which of the following stakeholders are served by the Health Information Management profession?

Healthcare provider

Which of the following would be considered a covered entity

health care provider

Which of the following would be considered a covered entity?

Patient

Who is responsible for maintaining a personal health record?

Who is the only person authorized to make a diagnosis? A. Care provider B. Healthcare professional C. Medical assistant D. Office manager

The mobile technology that allows access to the Internet without use of cables is known as what?

Wi-Fi

The medical office you work in recently transitioned into an electronic office and is implementing practice management software. You are excited about this change and are learning all you can about the new technology. However, some of your coworkers are having trouble grasping the basics, and are now saying they don't want to use the software at all. What steps could you take to assist your struggling coworkers?

You could offer to help them with issues they are finding with the software; ask your supervisor if it would be alright to do some quick training sessions; discuss all of the ways an electronic office will make your coworkers' lives easier in the long run. Remaining positive and ensuring that your coworkers feel supported are the most important keys to easing their struggles.

encryption

_____________ as a security measure in which words are scrambled and can only be read if the receiving computer has a had to read the message?

Administrative

__________data includes demographic data

Chief complaintt

_________is part of the appointment scheduling feature of prime SUITE

Occupation

________is part of a patients administrative information found on a registration form

To help guard unauthorized individuals accessing a practices computer system, a unique access code that is known only to the user is used. What is this unique access code called_____?

a password -Fill in

In a physicians office the equivalent of a hospitals master patient index is.....?

a patient list

Which of the following may result in the need to deploy the disaster recovery plan? a) A computer hacker has gained access to the database and corrupt files have been found b) Joy Smith, an employee in the office, entered data on the wrong patient c) The IT manager has read that a computer virus has just hit Europe and is expected to hit the United States by end of week d) Dr. Ingram lost his cell phone last week

a) A computer hacker has gained access to the database and corrupt files have been found

The Patient Centered Medical Home (PCMH) model was developed by the ________________. a) American College of Family Practitioners b) American College of Patient Centered Medical Homes c) American College of Internal Medicine d) American College of Medicine

a) American College of Family Practitioners

Who is the only person authorized to make a diagnosis? a) Care provider b) Healthcare professional c) Medical assistant d) Office manager

a) Care provider A care provider is the only one authorized to make a medical diagnosis.

____ is not easily attained when using a manual record system. a) Interoperability b) Maintenance c) Data capture d) Communication

a) Interoperability Manual record systems do not readily allow for interoperability.

a) Subjective Since information such as the duration of symptoms and modifying factors, such as taking a medication, come from the patient, this is considered subjective data.

A/an ___________________ report shows a summary but no details. a) aggregate b) surrogate c) custom d) standard

a) aggregate

a) chief complaint

The information contained in the encounter form is eventually transferred to the ________ form for submission. a) claim b) encounter form (Superbill) c) insurance d) registration

a) claim

A ________________ is a security method that prevents unauthorized access into or out of the network. a) firewall b) router c) modem d) decryptor

a) firewall

a) flag

Public health agencies have a particular interest in the administration of vaccinations. This information is kept in a/an ___________________ registry. a) immunization b) cancer c) disease d) trauma

a) immunization

EHR/EMR software is more comprehensive than practice management software because it: a) includes clinical documentation. b) submits insurance claims. c) is computerized. d) contains more menu options.

a) includes clinical documentation. EMR software contains a clinical documentation component, while PM software does not.

Lisa Haver is a patient of Dr. Randolph's. You have just opened today's mail and opened a letter from Ms. Haver's attorney because she is involved in a lawsuit regarding an auto accident. What will you do? a) look for a signed authorization in the envelope which authorizes the office to release Lisa Haver's records to the attorney b) print off the record from the EHR system and send to the attorney c) call the patient d) Write back to the attorney stating that your office policy prohibits you from sending records to attorneys

a) look for a signed authorization in the envelope which authorizes the office to release Lisa Haver's records to the attorney The very first step would be to find the signed authorization from the patient. If no authorization was enclosed, then a letter would be sent to the attorney's office requesting one.

Datasets that provide structure and are the building blocks for parts of the health record are known as ____________ files. a) master b) template c) patient d) provider

a) master

Which of the following professionals would not perform a physical examination (PE)? a) medical assistant b) physician's assistant c) nurse midwife d) nurse practitioner

a) medical assistant Since only care providers perform PEs, a medical assistant would not be qualified to do so.

Only services deemed medically ________ can be billed to insurance. a) necessary b) progressive c) restorative d) useful

a) necessary

The process of moving a patient from appointment-making through check-out is called: a) patient flow b) patient records c) patient process d) patient cycle

a) patient flow Patient flow is the term for moving a patient through the appointment-making and visit cycle.

Robyn Malone needs to determine the total number of patients assigned to each care provider for a report to Blue Shield. She will run a _________________ index. a) physician (provider) b) patient c) disease d) procedure

a) physician (provider)

HIPAA defines a patient's name, social security number, employer, or medical record/account numbers that tie information to a particular person as: a) protected health information b) privileged health information c) private health information d) confidential health information

a) protected health information

a) subjective information Information which is given by the patient is subjective.

An encounter form is also known as a/an: a) superbill b) claim form c) history d) EHR

a) superbill "Superbill" is another term for an encounter form.

Preformatted documents built into the practice management and electronic health record software are known as: a) templates b) master files c) forms d) screens

a) templates

Each person who has the ability to access a computer software system, for instance PrimeSUITE, is set up within the software and assigned a/an __________________, which is typically based on their name. a) user ID b) password c) PIN d) access code

a) user ID

Which of the following elements of an HPI are collected at a visit? a. All of them b. Duration, quality, and severity c. Location and severity d. Only those that apply to the patient's chief complaint

a. all of them

Which of the following would most likely require a complete review of systems? a. annual exam b. headaches c. mole on back d. sore throat

a. annual exam

Coding practices that are inconsistent with typical practice are known as:

abuse

Greenway Medical Center has partnered with five area physicians offices as well as a rehabilitation facility near by for the purpose of offering high quality coordinated care to patients in that geographic area. This partnetship is known as...

accountable care organization

HITECH regulations require that all information and releases be accounted for. This is called a

accounting of disclosures

You are the office manager of Greenburg Medical Centers. You have received a letter from one of your patients asking to know the names of all employees and care providers who have had accessed her EHR within the last year since she believes someone has been spreading information about her in the community. You will provide Miss Helthway with this information which is known as?

accounting of information disclosures -FIll in

For ease of completion, related information should be ____ on a form.

adjacent

For ease of completion, related information should be _________ on a form.

adjacent

For ease of completion, related information should be adjacent on a form.

adjacent

Demographic data is a subset of administrative data.

administrative

Jessie Lopez is a healthcare professional at Green Springs internal medicine. He has just finished submitting claims to blue shield for patients seen yesterday. Jessie is performing what type of function?

administrative

Demographic data is a subset of ____________________ data.

administrative. Demographic data is a subset of administrative data which identifies the patient and usually includes name, date of birth, gender, social security number, marital status, address, and telephone number.

Which of the following is not clinical information age

age

Of the following, who will benefit from thoroughly completed paper forms?

all of these

What information should you see on all forms in a patient chart?

all of these

according to HIPAA regulations, Healthcare providers must use_________ as opposed to written documentation to store and transmit information to insurance carriers

all of these

Which piece of information might be included multiple times on a form?

allergies

technical safeguard

an automated log off within an EHR system is an example of which of the following?

The master patient or master person index is a listing of ...?

an index of all patients ever treated at the hospital

accessible

and office compliance manual should be kept in a ______________ location.

Which of the following would most likely require a complete review of systems?

annual exam

A patient's past surgical history include the:

approximate date of the procedure

A patient's past surgical history includes the approximate date of the procedure

approximate date of the procedure

A patient's past surgical history includes the:

approximate date of the procedure.

A report that is run on demand is created:________?

as needed

Dr. Markunas saw Drew Panek in his office today. Drew was diagnosed with strep pharyngitis. The diagnosis is otherwise known as what in a SOAP note?

assessment

Access Control

assigning a unique name or number, as the way to identify and track a user's identity and prevent unauthorized users from retrieving electronic health information is an example of which of the following?

The subscriber and patient information section of a claim form includes all of the following except: assignment of benefits authorization

assignment of benefits authorization

The subscriber and patient information section of a claim form includes all of the following except

assignment of benefits authorization.

The subscriber and patient information section of a claim form includes all of the following except:

assignment of benefits authorization. The assignment of benefits refers to the payer, not the patient/subscriber.

A care provider is dictating a progress note into speech recognition while the patient is being seen. This dictation is occurring .....?

at the point of care

A care provider is dictating a progress note into speech recognition while the patient is being seen. This dictation is occurring: at the point of care

at the point of care

To check if a claim has been paid, which menu will the healthcare professional look at? a) Accounts payable b) Accounts receivable c) Claims processing d) Claim updates

b) Accounts receivable Posted claim payments are viewed in accounts receivable.

In 2004, the ______________, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology organized the Certification Commission for Health Information Technology. a) Centers for Medicare and Medicaid Services b) American Health Information Management Association c) American Medical Information Association d) International Federation of Record Organizations

b) American Health Information Management Association It was the American Health Information Management Association who partnered with the two organizations to form the Certification Commission for Health Information Technology.

What does the "CM" stand for in ICD coding? a) Care management b) Clinical modification c) Code management d) Coding methodology

b) Clinical modification The CM in ICD Coding stands for "clinical modification".

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) History and Physical b) Discharge Summary c) Progress note d) Procedure note

b) Discharge Summary For a hospital inpatient, the care provider must summarize the patient's hospital course; the final diagnosis and plan of care are part of the discharge summary.

A medical office or other healthcare facility that does not have a health information professional on staff may seek expertise in record-keeping procedures and the legal health record from the: a) care providers b) EHR service provider c) medical assistants d) local medical society

b) EHR service provider

Some states have a Health Information __________________, funded through the ONC, which allows the sharing of health information for continuity of care purposes. a) Bank b) Exchange c) Listserve d) Entity

b) Exchange Health Information Exchanges can be privately operated or can be state-run with funding by ONC or through the National health Information Exchange.

The law which strengthened HIPAA privacy and security regulations was: a) American Recovery and Reinvestment Act (ARRA) b) Health Information Technology for Economic and Clinical Health Act (HITECH) c) Meaningful Use (MU) d) Affordable Care Act (ACA)

b) Health Information Technology for Economic and Clinical Health Act (HITECH)

Which of the following is true of the advance payment ACO model? a) It is based on fee-for-service. b) It is an incentive model. c) It is the largest Accountable Care Organization. d) It requires participation by hospitals and medical vendors.

b) It is an incentive model.

Computers and devices that are physically close together are connected by a: a) Wide Area Network b) Local Area Network c) Broad Area Network d) Narrow Area Network

b) Local Area Network

The results of a patient's rapid strep test would be found in what area of a SOAP note? a) Subjective b) Objective c) Assessment d) Plan

b) Objective Measurable results, as in the case of a rapid strep test (positive or negative) are objective data.

A voluntary, pay-for-performance incentive program which care providers can participate in through the federal government is the: a) Pay for Performance Program b) Physician Quality Reporting Initiative c) Quality Reporting Initiative d) National Practitioner Data Bank

b) Physician Quality Reporting Initiative

How is a correction made to an electronic health record? a) The incorrect entry is corrected and the original entry is deleted from the database b) The incorrect entry is corrected and the original entry is hidden from view, but is still retrievable c) A second entry is made under the original incorrect entry and d) No change is made, since care may have already been given based on the incorrect information

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

A ____________________ is a security feature that plays a role in the advancement of EHR use by encrypting data sent via the Internet and verifies the identity of authorized users through use of a User ID and password. a) Private Internet Network b) Virtual Private Network c) Wide Area Network d) Local Area Network

b) Virtual Private Network

Meaningful Use requires that each patient, upon request, must be provided with a summary of test results, problem list, medication list, and medication allergies. This core objective is the: a) privacy provision b) ability to provide an electronic copy of health information c) ability to exchange key clinical information between/among care providers d) recording of a medication allergy list

b) ability to provide an electronic copy of health information

In PrimeSUITE, a red "X" on a Superbill summary indicates: a) an absent diagnosis. b) an invalid code assignment. c) a charge line will not be posted. d) a charge is ready.

b) an invalid code assignment. PrimeSUITE alerts users to an invalid code assignment by displaying a red "X" on the Superbill.

Nancy Jackson is the office manager of a medical practice. Each month she reviews a report that shows which staff members viewed, edited, or deleted data on a random selection of patient's records, and whether or not the access or the actions taken were justified. Nancy is performing which function? a) accounting of disclosures b) auditing c) quality review d) quantitative review

b) auditing

The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient's visit. a) care plan b) charges c) diagnosis d) assessment

b) charges

A computerized system which allows physicians to request lab, radiology, or pharmacy services for their patients is known as: a) electronic health records b) computerized physician order entry c) electronic prescribing d) orders requisition

b) computerized physician order entry

The process of ensuring a care provider has the proper qualifications to practice medicine before granting him privileges, contracting with him as part of a managed care plan, or hiring him in a medical practice is: a) checking references b) credentialing c) licensing d) accrediting

b) credentialing

In the long-term, costs will ____ when transitioning to an electronic health record system. a) increase b) decrease c) stay the same d) disappear

b) decrease Start-up costs are necessarily high, but the long-term costs of an EHR system are much lower than a paper-based system.

In the field "Primary Language", English appears in the field. This is known as a ___________ value. a) standard b) default c) absolute d) variable

b) default

In order for the healthcare facility to know what to do in case of a situation that interrupts access to the EHR, a written _______________ should be in place. a) policy b) disaster recovery plan c) compliance plan d) audit trail

b) disaster recovery plan

You have just entered data into an online form. The box in which you entered the information is known as a/an: a) locator b) field c) menu item d) space

b) field

To avoid negative consequences, a compliance plan should be ____ in every hospital and medical office. a) discussed b) followed c) used as a guide d) written

b) followed A compliance plan should be followed in every healthcare setting; this will help avoid negative consequences for improper actions.

b) in-network

The amount of a patient's co-pay may vary by: a) care provider. b) insurance plan. c) office location. d) visit type.

b) insurance plan. Each insurance company has different rules surrounding co-pays.

In order for Dr. Reynolds to send a CPOE from her office computer system to the computer system at the local hospital, a/an ____________________ must exist between the two computer systems. a) cable b) interface c) internet d) firewall

b) interface The two computer systems must be able to "talk to each other" or communicate in order for the sent message to be read by the receiving computer. This is known as an interface.

Some managed care plans encourage the use of clinical decision support (CDS) functionality by: a) making their use mandatory b) offering monetary incentives for care providers who utilize CDS c) including the provider's name in literature about CDS d) contacting patients to gain their support

b) offering monetary incentives for care providers who utilize CDS

b) orders tracking Orders tracking allows the provider and the healthcare professionals to know if a patient has given a specimen, whether the results are pending, or the order has been resulted (results sent to ordering provider).

b) patient education

b) patient portal

The SOAP documentation format is most commonly used in which healthcare setting? a) hospital inpatient b) physician's office c) hospital emergency department d) outpatient diagnostic department

b) physician's office Documentation in a physician's office is more precise and is related to what is wrong with that patient at the time of the visit. Therefore, SOAP note format is an efficient means to collecting the required information.

Clinical documentation of a patient's visit is known as the: a) point of care b) progress note c) medical claim d) superbill

b) progress note Clinical documentation appears in the form of a progress note.

A remittance advice is typically given to a/an ________ , whereas an explanation of benefits is typically given to a/an ________ . a) patient; provider b) provider; patient c) insurance company; patient d) provider; insurance company

b) provider; patient A healthcare facility will receive a Remittance Advice from the insurance company, while a patient receives an Explanation of Benefits.

During the history, Kevin Goodell notes that the pain in his right hip is more of a dull pain than an ache. This is considered what part of the history of present illness (HPI)? a) location b) quality c) severity d) modifying factor

b) quality A description of the type of pain is known as the quality element of the HPI.

A local newspaper reporter has contacted your office requesting the total number of patients in the practice who have a diagnosis of Lyme disease, broken into the following age ranges: newborn to 18 years old, 19 to 50 years old, and 51 and older, and by zip code. To answer this inquiry, the office manager will: a) run a standard report b) run a custom report c) run a benchmarking report d) run a detail report

b) run a custom report

b) scanning

Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _____________ are assistants who may enter the information. a) transcriptionists b) scribes c) dictators d) nurses

b) scribes Though it is possible that a nurse may be the assistant who does so, scribes are the professionals who are hired specifically to perform that task, and it is therefore the more accurate answer than nurse.

If a patient and his care provider conduct a conference call to discuss the patient's high blood pressure, they are engaging in _______________. a) teletechnology b) telehealth c) telemedicine d) telephony

b) telehealth

Which of the following is not included in the Notice of Privacy Practices? a) how a patient's health information may be used b) the name of the individual to whom a record was released c) that the patient may request correction or amendment to their health record d) entities to whom a patient's information may be released

b) the name of the individual to whom a record was released

The healthcare professional who types reports for care providers is known as a/an ______________. a) dictator b) transcriptionist c) transcriber d) scribe

b) transcriptionist A transcriptionist types reports dictated by care providers.

b) unstructured Since the nurse is typing this information in paragraph form and without the use of drop down menus, this is unstructured data.

Which of the following is NOT a required patient history? a. Family b. Birth c. Social d. Surgical

b. birth

A Healthcare professional will typically use an index to locate _________ information.

basic

A healthcare professional will typically use an index to locate______ information

basic

Philip is a medical assistant who has been working for a medical practice with two physicians and one physician's assistant for three years. He recently applied for a supervisory position within the office, but was overlooked for the position. He is anxious to take his knowledge and experience to the next level, but never took a certifying exam, and to this point has not taken advantage of continuing education opportunities. What is the best strategy for Philip to strengthen his chances of promotion in the future?

begin studying for one of the medical assisting certifying exam and schedule a date to take it Certification and continuing education show that the individual has incentive, background knowledge and current knowledge in his/her field.

Which of the following is NOT a required patient history?

birth

Ongoing communication about a particular topic. For instance, satification with a medical office, may be posted on a _____, a social media format where an author provides periodic commentary on varies issues?

EHRRRRR

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