EHR CH.1-10

Which of the following is a notation added to an office visit note after it has been permanently signed and locked?

Addendum

Which of the following entries in a patient's Care Tree are available to add into the body of a New Letter ABOUT Pt ?

All entries.

Selecting the [Dx] navigation tab produces a dialog window that allows the user to choose diagnoses from which of the following areas? Previous Diagnosis Problem List PMHX

All of these

What is the term used to describe the use of computerized tools to create and sign prescriptions?

E-prescribing

What is one benefit of an EHR over paper charts?

EHR is centralized.

All of the following are benefits of implementing EHRs except:

EHRs are more time-consuming than paper charts.

EHR is an acronym for

Electronic Health Record

Which of the following describes the function of the Patient Tracker ?

Enables all users across the network to see at a glance the current location and the status of all patients in the clinic.

Which of the following is represented by the acronym OV?

Office Visit

Because of the possible privacy threat to PHI, practitioners opt to communicate electronically with patients with which of the following methods?

Patient Portal

PMS is an acronym for which of the following?

Practice Management System

PHI is an acronym for which of the following?

Protected Health Information

What is meant by access authorization?

Specific assignable security levels regulate who may access, modify, delete, or transmit specific information.

Which of the following is a function that SpringCharts allows in regard to scheduled appointments?

SpringCharts gives the ability for a clinic to chart a no show for patients who do not show up for their appointments.

What did HIPAA establish?

Standards for accountability and criteria for the protection and confidentiality of health information that was transported electronically.

How does the log-in process for students using the single-user version of SpringCharts differ from that of an actual user of SpringCharts?

Student user name and password is embedded in the software

Which of the following is a report that provides information to the CDC to enable effective monitoring of rates and distribution of disease, detection of outbreaks, monitoring of interventions, and prediction of emerging hazards?

Surveillance Reports

Which of the following is a SpringCharts add-on feature that provides pre-built office visits notes, orders and letters, as well as pop-up text for specific specialists?

Templates

Which of the following indicates appointment intervals on the SpringCharts schedule?

10 minutes

Under the Template tab of the Office Visit Report Template Editor, the user can identify up to how many additional elements of the physical exam to include in a customized office visit report?

12

In what year was SpringCharts CCHIT-certified for ambulatory EHR?

2007

Which of the following describes the term "No Show"?

A patient who Misses a scheduled appointment without calling in advance to inform the clinic or reschedule.

Which of the following describes an Existing/Registered patient?

A patient whose information has been setup in SpringCharts database.

Which of the following describes a New/Unregistered patient?

A patient whose information has not been entered into SpringCharts database.

Which of the following describes the only instance a user will double-click while using SpringCharts?

Activating the SpringCharts icon on the desktop

The PMS is capable of managing which of the following tasks? Financial transactions Billing of insurance claims Patient statements

All of these

The cost of an EHR includes: The software purchase price, additional computer hardware, and training of staff Customization of the system, ongoing technical support, system maintenance, and future program upgrades None of these

All of these

What does the User Preferences window enable a user to do? Set the default physician's name Set the default practice name Set the default appointment schedule

All of these

What information is more available to doctors because of the inception of EHRs? Allergies Side effects Drug dosages

All of these

What is one criterion a user may select when searching for patients' information? Social Security number ZIP code Last name

All of these

Which of the following indicates a reason why patient appointments may change throughout the day? Cancellations Last minute scheduling Clinicians fall behind schedule

All of these

Which of the following information saved in SpringCharts EHR enables the system to prevent adverse medication reactions by performing drug-to-drug and drug-to-allergy checking? Allergies Sensitivities Routine Medications

All of these

Which of the following is NOT a component of meaningful use, as specified by ARRA? Electronic exchange of lab results EHR use to submit clinical quality reports e-Prescribing

All of these are components of meaningful use.

Which of the following could have been a reason for the lack of EHR implementation in the 1990s? Unknown cost and ROI. Doctors perceived EHRs were difficult to operate. Programs offered different features therefore data exchange was difficult.

All of these.

Which of the following information can be viewed as an illustrated graph as a result of graphing vital signs? Height/weight data. Body mass index. Blood pressure.

All of these.

Why did health-care providers perceive EHR systems to lack safety? The electronic medical record could be altered without his or her knowledge. Because of possible power outages. Because of possible computer "crashes."

All of these.

The advantage of accessibility means that the electronic chart is:

Always available even from a remote location via the Internet.

Which of the following is an office visit as defined by SpringCharts?

An encounter with a medical provider in which the patient's chief complaints, body systems, vitals, physical exam, diagnoses, and medication are reviewed and documented.

When should a patient be added to the Patient Tracker ?

As soon as the patient arrives in the clinic.

Why do HIPAA regulations affect EHRs?

Because of the portability of the patient's protected health information

Which of the following are issues the healthcare industry grapples with in creating necessary technology to guarantee total security of ePHI?

Both E-mail Security and Digital Signatures

Which of the following is a code set developed by the AMA and adopted by insurance carriers and managed care companies as the means for identifying common medical procedures?

CPT

Which of the following is NOT information that will print on a patient's Face Sheet?

Chart Alert.

Once the office visit note has been selected, how does a user create a report from the patient's chart without opening the OV screen?

Click the [Report] button

Which of the following is NOT automatically added by the EHR system to the new test report?

Clinician's digital signature

Which icon in the OV screen enables the provider to send a To-Do/Reminder to another person in the clinic or to him/herself?

Create a Reminder

Which of the following features is not a positive attribute of EHRs?

Decreased efficiency and savings

Which of the following best describes pop-up text?

Enables the clinic staff to rapidly select predefined text to complete office visits, letters, reports, etc.

Which of the following processes will not change as a result of implementation of EHR?

Examining the patient

From which menu can a user access the option to print a patient's history of diagnosis, prescriptions, or procedures?

From the Actions menu in the patient's chart.

Which of the following is a code set used to identify durable medical equipment and supplies, as well as some medical procedures as recognized by the CMS?

HCPCS

Which of the following provides practitioners and healthcare facilities who adopt EHR with financial incentives paid over a five year period through the Medicaid and Medicare programs?

HITECH

HIPAA is an acronym for:

Health Insurance Portability and Accountability Act

Which of the following are displayed on the tool bar in the Practice View screen?

Icons that give the user shortcut access to the most commonly used functions.

Which of the following is true regarding HIPAA privacy and a patient's disclosure of family medical history?

Individuals are free to provide their physicians with a complete family medical history and communicate about conditions that run in the family.

Which of the following describes a person admitted to a healthcare facility to stay overnight for an indeterminate amount of time?

Inpatient

Which of the following describes a method in which EHRs enhance communication between providers and their staff?

Instant messaging

Which of the following allows changes made in the PMS system to be reflected in the EHR in real time?

Interfacing

What does accessing the prescription [ Rx ] navigation tab display?

It displays an information window from the patient's chart related to Allergies and Other Sensitivities .

Which of the following is not a benefit of EHR?

Little or no training necessary

Which of the following describes the manner in which a provider may overrule the E&M Coder recommendation?

Manually selecting the appropriate factor category and making necessary revisions.

Which of the following refers to demonstrably effective utilization of an EHR program?

Meaningful Use

Which of the following is a storage area in SpringCharts for saved messages?

Message Archive

Which of the following is accessible to the message recipient when a message is connected to a patient?

More than one of these is accessible to the message recipient.

All e-prescribing from which of the following locations goes through a centralized clearinghouse before the prescriptions are transmitted to the indicated pharmacy?

Nation

What type of code sets must the EHR use?

National standard code sets

What feature would a user access to send a letter to a referring physician about a patient?

New Letter ABOUT Patient.

Which of the following mandate that a patient's routine medications and problem list be transmitted to the SureScripts clearinghouse each time an electronic prescription is sent?

ONC

When can activities regarding a patient be documented in SpringCharts EHR?

Only after the patient's chart is opened

Which of the following colors depicts a communication between a user and an administrator regarding requested changes to the time clock feature?

Orange

Which of the following acts allows for disclosure of PHI in relationship to terrorism?

PATRIOT Act

When an excuse note is created within the OV screen, which of the following appears by default in the subject line of the New Excuse/Note window?

Patient's name

Which of the following describes ordered tests that have not yet been processed?

Pending

PHR is an acronym for which term?

Personal Health Record

Which of the following is NOT a mode of data entry in EHR?

Photocopying from a paper chart

For which of the following does a patient pay a monthly premium for medical coverage?

Primary insurance

Which of the following is the foremost concern for healthcare providers and patients in the transition to EHR?

Privacy of sensitive information

Which of the following assist physicians with security risk analysis and address security deficiencies?

RECs

Which of the following features contain the procedure and diagnosis codes and descriptions that were selected in the office visit and are used for billing?

Routing Slip

Which of the following is an insurance policy that pays for some of the patient's medical expenses not covered by the primary health coverage?

Secondary insurance

Which of the following describes how a user can view all referrals for a particular patient in the Edit Face Sheet window?

Select Show All Referrals checkbox

Which of the following is an appropriate disclosure of protected health information?

Sharing any protected health information described here may violate HIPAA's privacy ruling.

Which of the following icons enables the user to choose which signature to place in the new letter about patient?

Signature

What is the definition of EHR?

Software with a full range of functionalities to store, access, and use patient medical information.

In which window are the various Location and Status options selected?

The Edit Tracker window

If a patient has no known drug allergies, which of the following can the physician report and still meet the meaningful use requirement?

The physician simply reports 'no known drug allergies'.

Which of the following describes how a user creates information recorded in the Diagnosis history, Prescription History, and Procedure history?

The program automatically records the information once selected in the office visit screen.

Which of the following explains why the Patient ID field is shaded gray?

The program will assign a Patient ID number after the information is saved.

What is the function of a time stamp?

To time stamp notes and other documents.

In which of the following windows are user-defined, meaning that only the user who makes the modifications can view the changes?

To-Do List and Messages

Which of the following are recorded using the settings established in the 'measurements' option in the User Preferences window?

Vital signs

Considering the options for office visit orientation, when is the placement of the pop-up text and navigation panels critical?

When a user accesses SpringCharts from a tablet computer

Which of the following describes the occasion to use theNew Vitals Only feature of SpringCharts?

When patients come into the clinic for the sole purpose of having their vital signs taken.

Which of the following is NOT an EHR competency as defined by CMC?

Write upgrades for EHR software.

Which of the following tabs allows the user to add a portion of or the entire face sheet to the office visit note by clicking on one or more of the category icons?

[FS]

Which of the following buttons in the message window gives the user access to the patient's routine medications?

[Rx]

Which of the following would be documented under the Objective in SOAP note format?

blood pressure

EMR is an abbreviation for which of the following?

electronic medical record