EHR QUIZ QUESTIONS

Which of the following is not a potential audience for documentation in the record: a. CDI specialist b. Aetna insurance c. Hospital marketing d. Patient's next of kin

Hospital marketing

Which of the following is a barrier to the implementation of EHR? a. Lack of standards b. E-prescribing options c. Identified ROI d. Increased patient safety

Lack of standards

The illegal access and use of patient's personally identifiable information to obtain medical treatment, services or goods is called: a. Fraud b. Medical Identity Theft c. Breach d. Misuse

Medical Identity Theft

Limiting PHI disclosed to the least amount required to accomplish the intended purpose: a. Disclosure b. Minimum Necessary c. Use d. Request

Minimum Necessary

Which of the following is elements of data integrity means all entries are correct and in the right chart: a. Complete b. Accurate c. Consistent d. Up to date

Accurate

Accuracy in data entry is important for which of the following reasons: a. Prevent medical errors b. Quality reporting c. Quality patient care d. All of the above

All of the above

In order to de-identify PHI which of the following must be removed: a. Name b. Medical record number c. Social security number d. Address e. All of the above

All of the above

Late documentation can lead to which of the following: a. Medical errors b. Misdiagnosis c. Poor quality care d. All of the above

All of the above

The government want EHR's in place for the following reasons: a. Control costs b. Improve healthcare efficiency c. Improve patient safety d. All of the above

All of the above

What qualities makes the EHR superior to the paper record? a. Easy to find data b. Ability to share data c. Ability to search for data d. All of the above

All of the above

Which of the following demonstrates Data Integrity? a. Complete b. Accurate c. Consistent d. Up to date e. All of the above

All of the above

Which of the following is a benefit of communicating through email: a. Fast b. Easy to use c. Reduces staff time d. All of the above

All of the above

Which of the following is a legal issue for email communication? a. Confidentiality b. Missed or overlooked content c. Record maintenance d. All of the above

All of the above

Which of the following is an example of good etiquette when entering patient information in the computer: a. Make eye contact b. Engage the patient in the information in the EHR. c. No bad mouthing fellow healthcare providers d. All of the above

All of the above

Which of the following is an example of problem documentation in court? a. Misspelling of drug names b. Incorrect grammar or spelling c. Text speak or shortcuts d. Documenting ahead e. All of the above

All of the above

Which of the following would be considered an "audience" for your documentation in the EHR? a. Medical staff b. Lawyers c. Joint Commission d. all of the above

All of the above

Which of the following is a way that EHR contributes to patient safely? a. Allergy alert systems b. Drug utilization review c. Elimination of illegible handwriting d. All of these

All of these

A hypersensitivity caused by exposure to a particular antigen resulting in a marked increase in reactivity to that antigen when exposed to it. a. Allergy b. Problem c. Posting d. Discharge Summary e. All of the above

Allergy

Which of the following is NOT a way to ensure data accuracy? a. Data editing rule b. Proofreading entries c. Allowing other providers to modify entries d. Correction of entries

Allowing other providers to modify entries

ARRA

American Recovery and Reinvestment Act

In the SOAP Note Format which area would the documentation, "Patient has pneumonia" fall into? a. Subjective b. Objective c. Assessment d. Plan

Assessment

Which of the following were created to provide support and guidance to help other communities achieve meaningful use and documenting best practices in EHR's. a. HIE b. Regional Extension Centers c. CMS d. Beacon Communities

Beacon Communities

Information technology was first used in healthcare for: a. Billing and collections b. Lab results c. Registration d. Administrative uses

Billing and collections

From the "Why Electronic Health Records" video an unconscious patient is unable to tell you: a. Medications he/she is on b. Drug allergies c. Insurance information d. Both a and b e. All of the above

Both a and b

When PIH is disseminated from the healthcare provider and sent to an external source: a. Disclosure b. Minimum necessary c. Use d. Request

Disclosure

For CPOE to send drug alerts for medical allergies or drug contraindications you need which of the following data: a. Nondiscrete data b. Discrete data c. Allergy data d. All of the above

Discrete data

Which of the following is the ability to transmit prescriptions electronically a. CPOE b. E-prescribing c. Medication Administration d. PACS

E-prescribing

Coded data in national standard code sets is needed for which of the following functions: a. Health maintenance b. Trend analysis c. Efficient exchange of data among systems d. Decision support e. Alerts

Efficient exchange of data among systems

EHR is an acronym for a. Emergency Health Record b. Electronic Health Record c. Emergency Health Repository d. Electronic Health Repository

Electronic Health Record

According to the FBI, 50% of breaches occur from providers own employees a. True b. False

False

Confidentiality is the right of an individual to keep information about themselves from being disclosed to anyone. a. True b. False

False

It is acceptable to wait until the end of the day to document. a. True b. False

False

Providers must report breaches involving over 300 people to the Office of Civil Rights. a. True b. False

False

Which of the following controls external access to a network? a. Access controls b. Alarms c. Encryption d. Firewall

Firewall

Which of following is not a vital sign? a. Heart rate b. Breathing rate c. Temperature d. Blood pressure e. Pain rating f. All are vital signs

Pain rating

Which of the following documentation is considered meaningful: a. Patient is not feeling well b. Patient has vomited 3 times in the last hour c. Patient is sleepy d. Patient slept a lot

Patient has vomited 3 times in the last hour

In the SOAP Note Format which area would the documentation, "treat with antibiotics" fall into? a. Subjective b. Objective c. Assessment d. Plan

Plan

Which of the following is not a function of the medical record? a. reimbursement of claims b. minimize malpractice claims c. platform to record complaints about other providers d. communication tool between healthcare providers

Platform to record complaints about other providers

POC is the acronym for a. Point of Care b. Provider of Care c. Politics of Care d. Physicians of Care

Point of Care

PMS

Practice Management System

A medical diagnosis or health condition that is identified and placed in the patient's medical record a. Allergy b. Problem c. Posting d. Discharge summary e. All of the above

Problem

PHI

Protected Health Information

The Red Flag rules apply to: a. All healthcare providers b. Business Associates of healthcare providers c. Providers that collect credit card information d. All of the above

Providers that collect credit card information

Which of the following is not a negative of communicating through email: a. Rapid communication b. No control over forwarding c. Misdirected Emails d. Too lengthy messages

Rapid communication

Which of the following is not a way information technology can reduce healthcare costs: a. Reduce duplicate testing b. Saving time c. Reduce staff d. Preventing medical errors

Reduce staff

REC

Regional Extension Centers

Which of the following was created to assist primary healthcare providers in adopting EHR's. a. HIE b. Regional Extension Centers c. CMS d. Beacon Communities

Regional Extension Centers

Which of the following is not a function of the Laboratory Information System? a. Saves text documents b. Prints out lab results c. Marks values as high, low or panic d. Prints labels for vials

Saves text documents

The protection measures and tools for safeguarding information and information systems is a definition of: a. Confidentiality b. Security c. Privacy d. Access control

Security

Which of the following functions of the EHR does not needs structured data: a. Health maintenance b. Trend analysis c. Sharing data d. Decision support e. Alerts

Sharing data

In the SOAP Note Format which area would the documentation, "Patient complains of chest pain" fall into? a. Subjective b. Objective c. Assessment d. Plan

Subjective

In the SOAP note format which area would you document "patient complains of headache" a. Subjective b. Objective c. Assessment d. Plan

Subjective

Under HIPAA a healthcare provider can disclose PHI without patient authorization for: a. ARRA b. DRS c. ARRA d. TPO e. None of the above you always need an authorization

TPO

Which element of data integrity is missing if the Radiology report is dictated after the patient is discharged: a. Complete b. Accurate c. Consistent d. Timely

Timely

TPO

Treatment, Payment & Operations

A Workflow Redesign Specialist will analyze an office workflow and recommend ways that the new EHR can be incorporated. a. True b. False

True

A negative issue that can result from communication through email is misinterpretation of the tone of the email. a. True b. False

True

A too lengthy email may lead to a legal issue for the provider. a. True b. False

True

A transcription company would be considered a Business Associate under HIPAA. a. True b. False

True

CPOE reduces errors caused by illegible handwriting. a. True b. False

True

Deidentified information is not subject to the HIPAA privacy rule. a. True b. False

True

EHR's provide timely access to all types of results, including laboratory results and radiology results, this helps providers make informed choices for diagnosis and treatment and increases quality of care. a. True b. False

True

HIPAA mandates that all EHRs have audit trails and these trails are monitored for potential security breaches. a. True b. False

True

Reimbursement is the payment of services for a third party. a. True b. False

True

The HITECH Act allows law enforcement and homeland security access to patients records under certain limited circumstances such as in relation to terrorism. a. True b. False

True

Which of the following means your data was documented at the time care was provided? a. Complete b. Accurate c. Consistent d. Up to date

Up to date

Which of the following is not a good practice for communication in the EHR? a. Quote the patient and family b. Communicate what you see and hear c. Use text shortcuts to cut down on the amount of documentation to save storage space d. Proofread your entry

Use text shortcuts to cut down on the amount of documentation to save storage space

When documenting which of the following practices should not be followed: a. Use text speak to speed up documentation b. Be professional c. Use proper grammar and spelling d. Proof read your entries

Use text speak to speed up documentation

Which of the following is an example of a security measure: a. Audit trail b. CDS c. User name and password d. All of the above

User name and password

Which of the following is not a purpose of the documentation contained in the medical record: a. Record providers assessment b. Validating patient satisfaction scores c. Meeting organizational and licensure requirements d. Minimizing malpractice claim

Validating patient satisfaction scores

Which method of data entry involves the computer typing the text as the provider is dictating: a. Dictation b. Document imaging c. Voice recognition d. Optical character readers

Voice recognition

DMS

document management system

EMAR

electronic medication administration record

GIGO

garbage in, garbage out

CDS

Clinical decision support

The group of records maintained by the healthcare provider that may include payment and medical information. a. PHR b. Designated record set c. PHI d. EMR

Designated record set

Unknowing violations of PHI that is uncorrected is subject to which of the following HIPAA penalties: a. $100-$25,000/violation b. $1,000-$100,000/violation c.$50,000-$250,000/violation d. $50,000-$1,500,000/violation

$100-$25,000/ violation

Willful neglect of PHI that is uncorrected is subject to which of the following HIPAA penalties: a. $100-$25,000/violation b. $1,000-$100,000/violation c. $50,000-$250,000/violation d. $50,000-$1,500,000/violation

$50,000-$1,500,000/violation

Willful neglect of PHI that was corrected is subject to which of the following HIPAA penalties: a. $100-$25,000/violation b. $1,000-$100,000/violation c. $50,000-$250,000/violation d. $50,000-$1,500,000/violation

$50,000-$250,000/violation

When the breach involve ____ patients or more the news media needs to be notified. a. 500 b. 750 c. 1,000 d. 1,500

500

All individuals whose information has been breached must be notified without reasonable delay, and not more than _____ days. a. 30 b. 60 c. 90 d. 120

60

An unauthorized use, access or disclosure of private health information that compromises the privacy and security of the information: a. Breach b. Incident c. Disclosure d. All of the above

Breach

Which of the following is a core objective for both physicians and hospitals. a. Report 6 ambulatory quality indicators to CMS b. CPOE c. Provide a summary for each visit d. List patients by condition/diagnosis

CPOE

Which of the following means your data has nothing missing? a. Complete b. Accurate c. Consistent d. Up to date

Complete

CPOE

Computerized Provider Order Entry

The expectation that information shared with a healthcare provider will be used only for it's intended purpose is the definition of: a. Confidentiality b. Informational privacy c. Informational security d. Technical security

Confidentiality

Which elements of data integrity would conflicting documentation not meet: a. Complete b. Accurate c. Consistent d. Up to date

Consistent

EH

Eligible Hospital

EP

Eligible Provider

Which of the following is not considered a covered entity under HIPAA: a. Pharmacy b. Physician office billing company c. Environmental service company d. Insurance company

Environmental service company

One of the major challenges in developing a computer-based patient record is the amount of _______________ in a health record. a. Demographic data b. Diagnostic data c. Free text data d. Discrete data

Free text data

GUI

Graphical User Interface

Which of the following is not a benefit of communicating through email a. HIPAA violations b. fast c. easy to use d. reduces staff time

HIPAA violations

Which piece of legislation passed in 2009, promoted and funded health information technology. a. HIPAA b. HITECH Act c. Affordable Care Act d. none of the above

HITECH Act

HIE

Health Information Exchange

HIT

Health Information Technology

HITECH

Health Information Technology for Economic and Clinical Health Act

HIPAA

Health Insurance Portability and Accountability Act

The right of an individual to keep information about themselves from being disclosed to anyone is a definition of: a. Confidentiality b. Informational privacy c. Informational integrity d. Security

Informational privacy

In the SOAP Note Format which area would the documentation, "CBC shows low hemoglobin" fall into? a. Subjective b. Objective c. Assessment d. Plan

Objective

ONC

Office of the National Coordinator

Which of the following are the instructions that control the computer? a. graphical user interface b. hard drive c. operating system d. device driver

Operating system

PHR

Personal Health Record

PACS

Picture Archiving and Communication System

Which of the following is an example of inappropriate documentation: a. The kitchen never sent a try up b. RN is not follow therapy recommendations due to patient noncompliance c. Dr. Jomes paged d. All of the above are examples of inappropriate documentation

The kitchen never sent a tray up

The HITECH Act spent _______ to accelerate the use of computerized health records in healthcare. a. $199 million b. $9.2 billion c. $99 million d. $19.2 billion

$19.2 billion

Which of the following are key elements for meaningful use: a. Clinical decision support b. Structured capture of quality measures c. Up-to-date problem lists d. Information exchange e. All of the above f. None of the above

All of the above

Which of the following caused providers to lag in acquiring and implementing electronic medical records in the first decade of the century: a. Lack of official industry standards b. Wide assortment of functionalities c. Absence of government regulation d. Both a and c e. All of the above

All of the above

Which of the following components make up data integrity: a. Complete b. Accurate c. Consistent d. Timely e. All of the above

All of the above

Which of the following errors can be reduced by using CPOE. a. Sound alike look alike drugs b. Misplaced decimal points c. Drug contraindications d. Misinterpreted abbreviations e. All of the above

All of the above

Which of the following is a benefit of HIE? a. avoids readmissions b. reduces medication errors c. improves diagnosis d. decreases duplicate unnecessary testing e. all of the above

All of the above

Which of the following is an administrative safeguard under HIPAA: a. Designation of a Privacy Officer b. Workforce training c. Process for handling privacy complaints d. All of the above

All of the above

Assists clinical decision making and also improves documentation and follow-up, by displaying specific tests and evaluations that are due based on the patient's age, vital signs, medical problems and documentation. a. Clinical reminder b. Order c. Posting d. Clinical decision support

Clinical decision support

A benefit of discrete data is it is easy to describe events a. True b. False

False

Data mining can be performed on unstructured data. a. True b. False

False

The report "To Err is Human" was published by: a. CMS b. HIPAA c. Institute of medicine d. HITECH

Institute of medicine

When PHI is reviewed by the Quality Department this is considered: a. Disclosure b. Minimum Necessary c. Use d. Request

Use

The list given to the patient of every person that has accessed the EHR is called: a. Audit trail b. Accounting of disclosure c. Access control log d. All of the above

Accounting of disclosure

The functions under HIPAA that should be implemented to ensure that security standards are met. a. Administrative safeguards b. Physical safeguards c. Technical safeguards d. All of the above

Administrative Safeguards

Data mining is used to identify methods for: a. Cutting costs b. Suggesting more appropriate treatment methods c. Predict medical outcomes d. All of the above

All of the above

From the "Future of Healthcare" video which of the following is a reason we need electronic health records: a. Better care b. Better health outcomes c. Better coordination of care d. Reduced costs e. Improved efficiency f. All of the above

All of the above

HITECH addressed the barriers to EHR adoption through which of the following: a. Establishing REC's b. Providing incentives c. Promoting health information exchange d. All of the above

All of the above

In which area can bar codes assist healthcare providers a. tracking patients b. tracking x-rays c. medication administration d. all of the above

All of the above

Structured data such as a patient's demographic data is considered: a. Limited b. Discrete c. Pre-defined d. All of the above

All of the above

A paper chart environment is less efficient and likely to produce errors because a. Illegible handwriting leads to misinterpretations of orders and prescriptions b. Paper records are often mislaid resulting in backtracking and searching c. Misfiled records cost time and money d. All of these are reasons that paper charts are less efficient and likely to produce errors.

All of these are reasons that paper charts are less efficient and likely to produce errors

The stimulus package of 2009 is officially known as: a. Centers for Medicare and Medicaid Services (CMS) b. American Recovery and Reinvestment Act (ARRA) c. Health Information Technology for Economic and Clinical Health (HITECH) Act d. Troubled Asset Relief Progam (TARP)

American Recovery and Reinvestment Act (ARRA)

Which of the following is viewed by the Institute of Medicine as one of the key features of an EHR that can improve quality of care, patient safety, and clinical efficiency. a. CPOE b. POC c. PAC d. EMAR

CPOE

The process of extracting and analyzing large amounts of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patients and using those relationships to predict behaviors is called: a. Trend analysis b. Data mining c. CDC d. Report mining

Data mining

Which of the following features is not a benefit of EHRs? a. Enhanced accessibility to clinical formation b. Improved patient safety c. Increased quality of patient care d. Decreased efficiency and savings

Decreased efficiency and savings

Digital images are stored in the Radiology Information System. a. True b. False

False

Document management systems are the same as an EHR a. True b. False

False

Information is the raw facts and figures expressed in text, number, symbols and images. a. True b. False

False

Which of the following is a non-profit national advisory group on health matters that set the gold standard for features that should be incorporated into electronic health records? a. Office of the National Coordinator b. Institute of Medicine c. Health Technology Curriculum Development Centers d. Regional Extension Centers

Institute of Medicine

The portion of the medical record released upon request is called: a. Legal Health record b. Hybrid record c. Electronic Health Record d. Personal health record

Legal health record

PHR is the acronym for: a. Personnel Health Record b. Public Health Record c. Personal Health Review d. Personal Health Record

Personal Health Record

Locks on computer room doors are what type of security control? a. Access control b. Workstation control c. Physical control d. Security breach

Physical Control

Locks on doors fall under which of the following: a. Administrative safeguards b. Physical safeguards c. Technical safeguards d. All of the above

Physical Safeguards

The automated controls used to protect electronic data and to control access. a. Administrative safeguards b. Physical safeguards c. Technical safeguards d. All of the above

Physical Safeguards

An example of unstructured data in a patient record is _______. a. Physician progress note b. Demographic data c. Coded diagnostic data d. Payor information

Physician progress note

Which of the following is not a main component for Meaningful Use as specified by ARRA. a. the use of a certified EHR in a specified significant manner b. the use of a certified EHR technology for the electronic exchange of health information c. the use of a certified EHR technology to submit clinical quality reports d. the use of a certified EHR technology for bioterrorism activities

The use of certified EHR technology for bioterrorism activities.

CPOE is the acronym for Computerized Provider Order Entry a. True b. False

True

Digital images require a licensed healthcare professional like a Radiologist to interpret the image. a. True b. False

True

Each user leaves a digital trail or "foot print" once they sign in the EHR. a. True b. False

True

One of the key attributes of the EHR is it should support a problem list that is able to be linked to orders and results. a. True b. False

True

Structured data reduces medication errors. a. True b. False

True

Templates and drop down boxes are examples of structured data. a. True b. False

True

The EHR has mechanisms for protecting confidentiality unlike the paper record. a. True b. False

True

The Pharmacy Information System, EMAR and CPOE close the medication management loop which reduces medication errors. a. True b. False

True

The expectation that physicians should be "experts" can lead to the resistance to the use of information technology. a. True b. False

True

The purpose of Clinical Quality Indicators is to improve patient health. a. True b. False

True

Small to average private medical practices were slow to implement electronic health reocrds due to: a. High cost of computer hardware and software b. Huge task of data entry c. Need to change office processes and procedures d. All of the above

All of the above

The Copy and Paste function has led to which of the following issues: a. Legal issues b. HIPAA issues c. Billing issues d. All of the above

All of the above

Which element of data integrity is missing if there is conflicting documentation in the chart? a. Complete b. Accurate c. Consistent d. Timely

Consistent

The Hybrid Record is 50% electronic and 50% paper. a. True b. False

False

The increased deployment of clinical systems means a reduction in staff. a. True b. False

False

The lab was the first department to be computerized in healthcare, a. True b. False

False

Which of the following errors potentially are eliminated with the implementation of EHR technology? a. Medication b. Transcription c. Both of these d. None of these

Medication

The process of making sure no medications were missed when a patient is transferred from on unit to another is called: a. Medication administration b. EMAR c. Drug formulary check d. Medication reconciliation

Medication Reconciliation

Which of the following would be considered discrete data? a. Operative report b. Medication dosage c. Physical examination d. Nursing notes

Medication dosage

Under the HITECH Act Eligible professionals need to meet all 15 of the Core Objectives to receive the incentive payments. a. True b. False

True

Which of the following describes how easy it is for users to accurately and efficiently accomplish a task while using an EHR. a. Skill b. Usability c. Competence d. Adoption

Usability

Which of the following is not a limitation to unstructured data: a. Easy to decribe b. Cannot perform CDS c. Limits data mining d. Limits report writing

Easy to Describe

Meaningful use was the name of ther certification program mandated by HIPAA. a. True b. False

False

The Health Insurance Portability and Accountability Act provided financial incentives, assistance, online tools and resources to providers to implement use and promote meaningful use of electronic health records. a. True b. False

False

Contain critical patient-related information about which healthcare professionals need to be aware. a. Allergy b. Problem c. Posting d. Discharge summary e. All of the above

Posting

Which of the following is not recorded by the EMAR. a. Dosages b. Route of administration c. Prescribing physician d. Time medication was given e. Who gave the medication

Prescribing physician

The which of the following is not a reason the government is mandating EHR's a. Control costs b. Improve patient safety c. Standardize documentation d. Improve healthcare efficiency

Standardize documentation

A detailed summary of the patient's hospitalization. It includes a plan of care for the patient after discharge a. Discharge order b. Discharge progress note c. Discharge summary d. Discharge posting

Discharge summary

Which of the following is a detailed summary of a patient's hospitalization? a. History and Physical b. Consult report c. Discharge summary d. Advance directive

Discharge summary

EMR is an abbreviation for which of the following? a. Electronic Medical Record b. Emergency Medical Record c. Electronic Medical Resource d. Electronic Method of Recording

Electronic Medical Record

Which of the following is an example of a problem that would not be included on the patient's problem list a. hypertension b. pain the left foot c. sinus infection d. history of appendectomy

History of appendectomy