Chapter 6 EHR true/false

An episodic illness or injury of limited duration that responds well to treatment

Acute condition

The height, weight, and size of the human body.

Anthropometric measurements

A brief statement of the problem, condition, or symptoms that prompted patient to seek medical attention.

Chief complaint

A prolonged illness that requires periodic follow up.

Chronic condition

A physician consultation with an established patient using a secure internet service.

E-visit

A patient is asked for his or her allergy history only during the first visit.

False

Evisits are illegal in most states.

False

Immunization status and administration need not be recorded for patients ages 18 and older.

False

Many errors in EHR medication lists are attributable to patients confusion about drug names and dosages.

False

Physicians using the EHR must use a structured method of data entry.

False

Voice recognition software does not eliminate the need to transcribe the providers office notes.

False

A medication that poses a heightened risk of injury or death when improperly administered.

High-alert medication

The duration, location, severity,context,associated signs and symptoms, quality, and modifying factors related to a patients illness.

History of present illness(HPI)

The process of comparing the medication list in the EHR to the patients self-report.

Medication reconciliation

Readily seen, perceived, or measured by the clinician.

Objective

An organized inventory of each organ system.

Review of symptoms

Perceived only by the patient and not evident to or measurable by the clinician.

Subjective

A medication list must be reconciled and updated in the EHR during each patient encounter.

True

A medication reconciliation should be preformed when a patient is removed from the operating room to the recovery room.

True

Patient instructions should be preformed in a well lighted area with limited distractions.

True

Speech recognition software can distinguish on voice from another.

True

The chief complaint includes all of the health concerns a patient is seen for during the course of a physicians visit.

True

The digital signature helps ensure the security of the patients information.

True