EHR 7
Templates can be used for various types of reports, such as:
All of the above
Immunization registries are a great public health tool that allow:
All of the answers are correct
Syndromic surveillance is a process that requires:
All of the answers are correct
The observed benefits of e-prescribing include:
All of the answers are correct
Use of cloned progress notes without any updates to reflect patient changes is dangerous because it:
All of the answers are correct
Which of the following is an example of clinical outputs?
All of the answers are correct
Which of the following is true about the automated data collection?
All of the answers are correct
The National Patient Safety Goals are part of an initiative that is focused on patient safety practices and activities. Which of the following is NOT an example of such activities?
Assuring automated data collection
Which of the following is NOT a public health objective of Meaningful Use Stage I?
Capability of EHR to submit protected health information data
Clinical outputs consist of meaningful information extracted from a patient's record. Which of the following is an example?
Cumulative report of lab results
Data mining is a process that involves researching the electronic records using certain criteria and then analyzing the information to identify issues and trends among the patient population. For this process to work, what is required?
Data and queries
An HIM professional is searching through the electronic lab reports and extracting those with high blood sugar in order to identify patients with high risk for diabetes. What is this process called?
Data mining
Which of the following is NOT a benefit of using a template?
Ensures automated data collection
Which of the following would NOT be a reportable laboratory result?
Findings of streptococcus
As Dr. Lee is visiting a patient, she notes: "Patient has ongoing diabetes. Vital signs are normal. Patient complains of abdominal pain. Plan to do an abdominal ultrasound." In what document will such information be found?
History and physical
Which of the following is an example of structured data?
Laboratory values
A chief complaint is part of the history and physical. Of what does it consist?
Patient's reporting the reason for his admittance to the ER
Which of the following statements is NOT true about well-designed EHR systems?
Physicians using EHRs love it because they no longer need to sign documents.
Clinical inputs include structured and unstructured data. What is the difference between these two types of data?
Structured data is stored in fixed database fields; unstructured data is mostly narrative.
A patient is complaining of chest pain that is sharp at times. What type of information is this considered?
Subjective
Which of the following is true about specialized templates?
They are designed to capture details about specific conditions.
What is the general purpose of the OIG Work Plan?
To ensure good documentation, coding, and billing practices
After checking the lab results and visiting the patient, the nurse practitioner orders a course of antibiotics. In which part of the history and physical would this be documented?
Treatment plan
Which of the following might provide greater incentive for physicians to enter patient data directly into the EHR?
Use of templates
An example of clinical input is:
a diagnosis code.
The term syndromic means:
a group of symptoms that when grouped together may indicate a disease.
A cloned progress note differs from a progress note in that it is:
a partial or total copy of a progress note.
A template is:
a preformatted file with prompts to collect specific information.
As a physician is prescribing daily baby aspirin for a patient, a message pops up that says the patient is allergic to aspirin. This is an example of a(n):
alert
A physical exam is a component of the patient's history and physical and includes all of the following EXCEPT:
allergies.
Family practitioners at Sun Rise Practice are now using tablets throughout the day as they visit patients and move around the facility. They receive ongoing e-mails alerting them of patients' critical test results. This is an example of:
automatic method of results entry.
Physicians, nurses, and other clinicians enter patient data into the EHR either during or after interacting with the patient. This data is considered:
clinical input.
A drug is generally considered a controlled substance if it is has the potential for all of the following EXCEPT:
drug interaction
Reportable laboratory results reporting under meaningful use requires:
electronic transfer of data from laboratories to public health agencies.
An e-prescribing feature can do all BUT:
ensure patient compliance with medication.
A history is a part of the patient's history and physical and includes all of the following details EXCEPT:
general appearance.
Automated data collection is better than manual data collection because:
it is more efficient and consistent.
A manual method of results entry differs from the automatic method of results entry in that:
it requires scanning of the report in the EHR.
Progress notes are an important part of the patient's record because they include:
multidisciplinary notes on how the patient is responding to treatment.
All of the following EXCEPT _____ are examples of unstructured data.
patient's gender
A requirement resulting from the Controlled Substances Act of 1970 states that:
prescribers must use a hard copy or printed prescriptions when ordering schedule II controlled substances.
As the doctor checks the patient's skin and muscle tone, he notes, "Muscle wasting." Such information would be part of a:
review of systems.
Manual data collection is accomplished by:
staff members who type it directly into the computer.
When the transcribed report is transmitted from the transcriptionist's computer to the patient's EHR, the report is _____ into the EHR.
uploaded
Clinical results reporting is one of the EHR features used to:
view lab and test results immediately.
