Electronic Medical Records Mid Term

A care provider determines the extent of the PE based on which of the following?

-The patient's chief complaint -The patient's responses to the ROS questions

Which of the following functions would be performed in practice management software?

- Capturing demographic information - Listing patients

Which of the following statements apply to registration?

- Centralized registration is done in one main location. - Decentralized registration is done in various departments.

Which of the following is included in the documentation for a patient visit?

- Chief Complaint - Medication Review - History of Present Illness

Demographic information

Data that identifies a patient

Why was the CCHIT founded?

Develop certifying criteria for the functionality, interoperability, and security of EHRs

Which of the following is a data source for the EHR?

EMR

What were the first versions of voice recorders called?

Ediphone and Dictaphone

What is the amount charged for services rendered in a physician's office, as organized by Current Procedural Terminology code?

Fee schedule

Which of the following describes a review of systems?

It includes signs or symptoms the patient is experiencing.

Why should the health record be accurate, precise, reliable, and consistent?

It is a legal document and ensures quality medical care.

Which of the following is true of patient documentation on the history form?

It sometimes contradicts information discovered during the patient interview.

What is the minimum number of personal identifiers that patients should be asked for?

Two

Blood pressure, temperature, and pulse are ________.

Vital signs

Which of the following are examples of professional organizations that provide members with up-to-date field information, networking opportunities, and continuing education?

- AMT - AHIMA - HIMSS - AAMA

Which of the following occurs during the registration process?

- Administrative data is collected and corrected. - Administrative forms are signed. - Authorization forms are signed.

Which of the following would be considered demographic data?

- Adress - Ethnicity - Full name

Which of the following are functions of clinical decision support?

- Alerts providers to patient diagnoses contained in the EHR - Offers suggestions for treatment options - Alerts providers to possible medication interactions

Select the ways that practice management software greatly improves the efficiency of a claims process.

- Allows for more accurate capturing of charges - Offers a variety of reporting options - Submits automatic reminders

What are some advantages to electronic health records over paper records?

- Allows for searching of patients by Social Security number or date of birth - Provides tracking of activity within the record

Which of the following apply to the use of a single database for PM and EHR?

- Allows for sharing of documentation with other healthcare providers - Allows provider to concentrate on patient care - Improves the quality of documentation collected

Which of the following claims processes should have written polices?

- Fee schedule - Follow-up on unpaid claims - Collections procedures - Timing of filing claims

Which of the following are examples of objective findings?

- Patient's blood sugar is 96 - Patient has a temperature of 101.2oF

What should be included on each page of a multi-page form?

- Patient's medical record or chart number - Patient's name

Which of the following are considered demographic data?

- Patients full name - Date of birth - Race

Which of the following are examples of healthcare facilities?

- Physician's practices - Hospice - Dental practices - Ambulatory surgery centers - Hospitals

The Electronic Healthcare Transactions, Code Sets, and National Identifiers Rules require which of the following?

- Providers must be compliant with standardization of electronic collection and exchange of health information. - Providers must submit claims electronically. - Providers must receive electronic information from insurance companies.

Which of the following are among the eight core functions of an EHR, as identified by the Institute of Medicine?

- Reporting and population health - Decision support - Patient support - Health information and data

If a patient comes in with a cough, difficulty breathing, and painful urination, which of the following body systems would the provider check?

- Respiratory - Genitourinary

Why is it important that the design of paper forms be logical?

- To minimize the amount of time it takes to transfer the information - To minimize the likelihood of having missing or incorrect information end up in the EHR

Claim details on a CMS-1500 or UB-04 claim form include which of the following?

- Total charges submitted - Place of service code - Amount collected from patient

A co-pay is a ________.

A fixed amount due at the time of service

What is a Master Patient (Person) Index?

A listing of all patients seen in an office or hospital

What does FH indicate?

A patient's family medical history

Master Patient Index

A permanent listing of all patients who have received care in a hospital (inpatient or outpatient)

Which of the following is an advantage of using PM software?

Ability to track patient flow

What are groups of doctors, hospitals, and other healthcare providers who form a voluntary partnership that result in coordinated, high-quality care to their Medicare patients?

Accountable Care Organizations

When is insurance verification usually completed by the office staff?

Before each visit

What are two types of registration that may be used at an organization?

Centralized and decentralized

CPT

Choice Coding system used to convert narrative procedures and services into numeric form

_______ is used within electronic health records to access current information about a disease or condition.

Clinical decision support

The relationship between the procedure code and the diagnosis that shows medical necessity is called which of the following?

Code linkage

What type of plan should be in place in every medical office and hospital in order to defend the practice in the event of a visit from the OIG?

Compliance

What does CPOE stand for?

Computerized Physician Order Entry

What information does a problem list typically contain?

Current and active diagnoses

What comes together to form information?

Data

A recap of vital signs is in which part of the ROS?

General

Which Act, passed in 1996, has set standards for storing, maintaining, and sharing electronic health records and ensures the privacy and safety of health information?

HIPPA

The ONC is mandated by which legislation?

HITECH

The use of electronic health records is a healthcare requirement due to the ______ Act.

HITECH

What are the benefits of using the Help feature?

Helps users understand the system better

Which of the following are features of PACS?

Improved image quality

What is the process of contacting the insurance carrier and receiving validation of coverage for the patient?

Insurance verification

On what tab are the resulted orders shown?

Lab Flowsheet tab

Archiving costs for electronic health records are considered _____, because it is storing the data on disk or server space.

Low

A reimbursement system that replaces the Sustainable Growth Rate formula previously used by Medicare Part B with a value-based system is called:

MIPS

Which of the following promotes quality, cost-effective healthcare through the monitoring of patients, preventive care, and performance measures of providers?

Managed care plans

Standards that replaced the Medicare Electronic Health Records, which was also known as:

Meaningful Use

A(n) _________ is a unique number assigned to each patient seen by a facility or office.

Medical record number

Services rendered to a patient cannot be billed to insurance unless they are proven to be _______ necessary.

Medically

Provider information on a CMS-1500 or UB-04 claim form includes which of the following?

NPI

A unique identifier that must be used on insurance claims to identify the care provider and/or group practice that rendered care to the patient is called a(n) ______.

National Provider Identifier

The principal federal entity charged with coordination, implementation, and use of health information technology and the electronic exchange of health information is the _______.

ONC

Objective information is which of the following?

Observational findings during an exam

Point of care refers to which of the following?

Occurring at the time the patient is seen

How many times should each piece of data be requested on a given form?

Once

When should a patient be entered in the practice's database?

Only once upon first visit

Which of the following types of software primarily carries out administrative functions and operations in a medical office?

PM

What type of forms are often used as source documents for the purpose of obtaining data for entry into the EHR?

Paper

Where would you find anesthesia reactions or complications, if any?

Past surgical history

The _______ element of SOAP documentation includes follow-up and treatment.

Plan

Due to the differences in insurance plan rules, it is important that the computer system efficiently applies which of the following to the correct patients when filing claims?

Policies

When registering a patient, you are putting them in which type of software?

Practice management

PHI stands for ______.

Protected Health Information

Which of the following is necessary to ensure that enough time is provided for appointments?

Reason for visit

Being "checked in" to a medical practice is considered _________.

Registration

Which EHR capabilities allow for fast, reliable data submission and retrieval?

Report-writing

What does ROS stand for?

Review of Systems

On a paper form, what should be sufficiently provided for the answer to each field?

Space

Subscriber information included on a CMS-1500 or UB-04 claim form includes which of the following?

Subscriber's name

Which entity enforces the Privacy Rule?

The Office of Civil Rights

ICD-10-CM/PCS

The classification system used to convert narrative diagnoses and procedures into alphanumeric codes

Which entity is typically responsible for the scribe?

The provider

Who distributed the first versions of voice recorders?

Thomas Edison, Inc. and Columbia Graphaphone company

What does speech recognition technology do?

Translates spoken words into a written format

After receipt of claims by the insurance carrier, the claim undergoes a process called ___________.

adjudication

Filing an insurance claim for a patient is and example of an _____ function.

administrative

Procedures and diagnoses are converted to a(n) _________ form in order to file claims to insurance companies.

alphanumeric

Software that has a special purpose, or function, is called a(n) _______.

application

The _______ findings of SOAP documentation include measurable information or observed findings that the care provider gathers from performing a physical exam.

assessment

Every patient in a healthcare facility is ______________ for the care he or she receives.

charged

Showing the relationship between a procedure that was performed and the diagnosis to support medical necessity is known as ____________.

code linkage

Ensuring that claims are _________ before sending them to insurance carriers will provide the best payment results.

correct

Administrative information that identifies the patient is called _______.

demographic data

Speech recognition technology allows documentation to occur on the computer screen as the care provider _____ notes.

dictates

What is the term for when a patient checks out of the hospital?

discharge

Software that recognizes the words being said by the person dictating and digitally converts the speech to text is called ____.

speech recognition technology

After patient information is initially entered into a practice management system, it will then populate into a practice's __________.

electronic health record system

The _________ well-being of a medical office is of great importance if the practice is to stay in business.

financial

If a care provider is sanctioned from Medicare, that means the provider is __________ to accept Medicare patients into his or her practice.

forbidden

The Master Patient Index (MPI) contains ________.

identifying data on each patient

Participation in the CMS performance categories of MIPS gives providers _____________ in the form of performance-based payment adjustments.

incentives

Raw facts that have meaning when viewed as a whole are considered _______.

information

On the Superbill, each CPT code must ________ to a diagnosis code, because the diagnosis code shows medical necessity.

map

Records are filed by _______ in a hospital setting.

medical record name

A treatment plan is also referred to as a(n) ______.

plan of care

The term __________ is typically used in physicians' practices to describe the administrative functions performed using computer software.

practice management

Administrative functions in medical practices are handled by ________.

practice management software

An organization that assists healthcare providers with the selection and implementation of electronic health record systems is called a(n) ______.

regional extension center

An assistant who enters data into the health record as the care provider dictates recent findings is known as a(n) _______.

scribe

An appointment time for a patient with an earache might be assigned a(n) ______ length of time than a patient who needs a physical exam.

shorter

Which of the following describe the purposes of regional extension centers?

- Assist in training staff on the use of EHRs - Provide technical assistance and guidance - Share best practices in selection, implementation, and maintenance of EHRs - Assist in satisfying Meaningful Use requirements

What might be some disadvantages to the use of electronic health records?

- Concerns about sharing information - Learning curve for care providers - High cost of initial impementation

Which of the following apply to electronic health records?

- Documentation by care providers tends to be more detailed. - Staff and physician training can be time consuming. - Misfiling is not an issue if the patient's name is spelled correctly.

Which of the following are computer applications?

- Electronic health records - Practice management - Word processing

How do medical practices see returns on their investments with the use of electronic health records?

- Enhanced patient safety - Less duplication of effort - Instant access to patient records

Using practice management (PM) software accomplishes which of the following?

- Filing of claims - electronic payment of claims - Great billing accuracy - Follow-up of claims

What type of costs are gradually lessened once a EMR/EHR system is in place?

- Filing supplies - Long-term storage - Physical space needed for record storage

Being found guilty of either fraud or abuse can result in which of the following?

- Imprisonment - Monetary fines - Sanctions

Which of the following describe interoperability?

- Information can be shared within applications of the same computer's system - Information can be shared between computer systems

Which of the following apply to HIPAA?

- It sets standards for storing, maintaining, and sharing electronic health information. - It includes regulations for employees to keep insurance after leaving their employment. - It was passed in 1996.

Diagnoses, procedures, and services are converted to alphanumeric forms in order to do which of the following?

- Keep statistics of conditions treated - Keep statistics of procedures performed - File claims to insurance companies

Which of the following are typical responsibilities of a scribe?

- Locate information in the EHR - Transcribe information in the EHR - Enter information into the EHR

Which of the following are typical elements of an HPI?

- Location of the condition - Duration of the condition - Severity of symptoms

The clinical aspects of an office visit include which of the following?

- Medical history - Vital signs - Provider exam

Which of the following are benefits of belonging to a professional organization?

- Networking opportunities - Continuing education opportunities - Up-to-date information about fields

A physical exam can be done by which of the following types of providers?

- Nurse midwife - Physician - Physician's assistant

Which of the following are examples of the assessment component of SOAP documentation?

- Patient is diagnosed with congestive heart failure - Provider suspects patient has coronary artery disease

Why is the problem list helpful to the patient as well as the provider?

- Patient may not remember when they had a surgery. - Patient may not remember when they were diagnosed with asthma. - Patient may not remember when they were diagnosed with diabetes.

Which of the following are part of payer information on a CMS-1500 or UB-04 claim form?

- Plan identification - Address of payer

Which of the following describe the intent of the HIPAA Privacy Rule?

- Protect the use of PHI - Ensure the privacy of health information

Which of the following terms describe documents often used in medical offices to capture diagnoses and services or procedures performed for billing purposes?

- Routing slips - Encounter forms - Superbills

Which of the following apply to paper-based records?

- Startup costs are relatively inexpensive. - Individual records can easily be lost or misfiled. - Archiving costs are high.

Select the ways that practice management software greatly improves the efficiency of a claims process.

- Submits automatic reminders - Offers a variety of reporting options - Allows for more accurate capturing of charges

Which of the following is true of the use of EHRs and regulatory compliance?

- The process of regulatory compliance is more efficient. - Regulatory compliance is easier. - Report-writing capabilities are available.

Which of the following are true of speech recognition technology?

- The software is not always 100% accurate. - Speech is converted into text.

Which of the following are true of electronic health records?

- They are comprehensive records for patients - They are legal records

Select all that apply. The objective of an EMR/EHR is to:

- capture accurate information - capture usable information - provide for coordination of care - capture timely information - protect the legal interests of the patient and provider

According to the January 2019 article by the U.S. Department of Health and Human Services Patient Safety Network, research showed what regarding the adoption of EHR use?

- enhanced safety attitudes - decrease in medical errors - improved guideline adherence

In which of the following ways are HIM professionals responsible for data?

- storage - capturing - handling

In order to select, implement, maintain, and use practice management software or EHR, a team of professionals is assembled to investigate software options. Those on the team should include:

- those that know the stiff regulations that govern health information - those that know how to use the software - those that understand the use of the software

Each patient may have more than one ____________ attached to the master entry.

- visit - encounter

What are some common libraries that built in the practice management software to perform functions within various applications?

-Alerts -Fee schedule -Reports -Insurance company -Code tables

A diagnosis of the patient's condition is known as a(n) _______.

assessment