Title: The Electronic Health Record for the Physician's Office with SimChart for the Medical Office

Which of the following healthcare professionals might use or be exposed to the EHR?

Physicians and physician assistants Medical coders Medical Assistants

According to the HIPAA _________ Rule, a medical practice must grant users the minimum necessary access to PHI (personal health information) they need to perform their job function.

Privacy

__________ refers to the patient's freedom to determine when, how much, and under what circumstances his or her medical information may be disclosed.

Privacy

HIPAA mandates measures to protect which of the following:

Privacy Confidentiality Security

Which of the following is an example of one of the 10 objectives and measures under stage 3 of the Meaningful Use incentive?

Protect electronic health information created or maintained by the CEHRT (certified health record technology). Use computerized provider order entry for medication, laboratory, and radiology orders. Generate and transmit permissible prescriptions electronically.

Which of the following would serve as the strongest password?

RitbditW2#

True or False:As required by the Patriot Act, the U.S. government has the right to see a patient's EHR without authorization in many circumstances, including government officials and/or agencies, such as workers' compensation, law enforcement officials, and medical examiners.

True

The practice of giving two or more patients the same appointment slot with the same provider is known as ______________.

double-booking

A documented interaction or visit between a patient and a healthcare provider is known as a(n):

encounter

According to proper telephone etiquette, one should answer the phone by the ______ ring, if possible.

fourth

_____________ safeguards require the medical practice or other covered entity to adopt formal processes to prevent, detect, contain, and correct security violations.

Administrative

Which of the following would be categorized as a common type of phone call in a medical office?

Appointment requests Requests for medical advice from a physician Insurance and billing questions

True or False:If a family member is in the room with a patient when the physician enters to deliver test results, the family member must leave the room unless signed consent is on file, even if the patient verbally confirms the family member can stay

False

True or false:The mantra in the medical field for documentation is "if it hasn't been documented, it might have happened."

False

____________ appointments are used to indicate a time that a provider is unavailable due to a lunch, out-of-office time, office hours, or holidays.

Block

When completing a patient referral, which of the following would be required to complete the form?

Both the authorization # and NPI #

_____ is a set of patient-centered tools embedded within EHR software than can be used to improve patient safety, ensure that care conforms to published protocol for specific conditions, and reduce duplicate or unnecessary care and its associated costs.

CDS (clinical decision support)

____________ is the obligation of professionals to keep a patient's information in confidence, which is protected by law to varying degrees.

Confidentiality

____________ refers to the right of an individual to have all of his or her information, including health information, kept private.

Confidentiality

Permission given to a covered entity for uses and disclosures of protected health information for treatment, payment, and healthcare operations is known as:

Consent

______________ is a key aspect of quality that encompasses planning and coordination of care, communication among members of the health team, and accessibility and transportability of information.

Continuity of care

Phone messages that have been saved to the patient record can be viewed in the ________ section of the Patient Dashboard.

Correspondence

In SimChart, a new patient welcome letter template can be found with the ___________.

Correspondence icon

After completing and saving a patient referral to the patient record, the completed and saved document can be viewed in the _____________ section of the Patient Dashboard.

Forms

The _____________________ established privacy standards for the use and disclosure of individually identifiable health information, promotes patients' understanding of their privacy rights, and helps patients control the ways in which their health information is used and disclosed.

HIPAA Privacy Rule

When completing a referral form, ________ codes are used to designate the diagnosis that the patient is being referred to the specialist for.

ICD

Which of the following are considered advantages of EHR?

Improved quality and continuity of care Increased efficiency Improved documentation

_________ is the process of separating closed records from active ones to be stored elsewhere.

Integrating patient records

the ability of separate EHR systems to share information in compatible formats.

Interoperability

Under the ______________ incentive program, eligible professionals or physicians implementing EHR systems are required to demonstrate 10 objectives and measures related to EHR use.

Meaningful Use

Which of the following are examples of U.S. government agencies or officials generally exempt from the HIPAA Privacy Rule?

Military healthcare plans Workers' compensation Correctional institutions

According to the HIPAA regulations, patients have a right to:

View or receive copies of their health records Have inaccurate health information corrected Opt out of sharing information with certain people

Safeguards designed to avert security breaches and provide contingency plans can occur in the form of:

administrative safeguards physical safeguards technical safeguards

Electronic breadcrumbs that reveal the trail each of us leaves behind as we move through the EHR system is known as a(n) ________ trail.

audit

A(n) ______ patient is a patient who has not been seen in the past 3 years.

inactive

If an employee in a medical office were to witness an accident, such as a physician tripping on a rug, the employee who witnessed the incident should complete a(n):

incident report

The ____ is the primary source of information about the patient's medical history, such as immunization records, operative reports, and progress notes.

medical record

The HIPAA Privacy Rule centers on a privacy standard know as the ______________, which requires that covered entities limit unnecessary or inappropriate access to and disclosure of protected health information.

minimum necessary standard

A(n) ________ is a sequence of characters and sometimes spaces used to prevent unauthorized access to or disclosure of patient information contained in secure electronic files.

password

Socioeconomic data such as age, sex, marital status, and education are all considered

patient demographics.

The goal of efficient scheduling is to optimize __________ through the office, which is the efficient movement of patients through the medical office as a product of accurately estimated patient volume, a consistent provider pace, and efficient schedule practices.

patient flow

Good communication accomplishes which of the following:

Improves patient confidence Helps prevent medical errors Reduces the likelihood of law suits

EHR backups should occur no less than:

Once an hour

The HIPAA ___________ Rule is supposed to ensure that information is not destroyed by natural disaster or some more malicious means, and that only people who are supposed to have access to PHI (personal health information) can gain access to it that's in line with their job functions.

Security

True or False: Many medical facilities may require or prefer their employees are crossed-trained, which means being able to perform more than one duty or skill across various task areas.

True

True or False:Audit systems can track the electronic breadcrumb trail each user leaves behind as he/she navigates through the EHR system.

True

A medical record number is generated ____________.

automatically

Clinical records, such as the Chief Complaint, the Health History, and the Immunizations records can be found in the ____________ module of SCMO (SimChart for the Medical Office).

clinical care

________ settings are a preselected value or setting that will be used unless the user specifies a substitute by overriding the preselected choice.

default

Socioeconomic data, such as age, sex, martial status, education, occupation, language, race, and ethnicity are known as:

demographic information

Secure e-mail is an inexpensive, efficient system for exchanging messages through the Internet using secure ________________, which is a system that keeps data secure by converting them to an unreadable code during transmission and then unencrypting the information when it reaches the recipient.

encryption technology

Which of the following forms of information are considered clinical information?

hospital records, progress notes, MRI films, and physical assessment findings

The ____________ provision of the HIPAA Privacy Rule mandates that when a covered entity makes an allowed disclosure, it should include only the minimum necessary amount of information to accomplish the task.

minimum necessary standard

The percentage of patients in a practice who arrive for appointments as scheduled or call in advance to cancel or reschedule is known as the office's _______.

patient flow

A _______________ is a secure website where a patient can access personal health information, schedule appointments, and refill prescriptions 24 hours a day using a username and password.

patient portal

A patient who has been seen within the past 3 years is considered a(n)

retention period

The process of assessing threats to the confidentiality, integrity, and availability of PHI is known as:

risk analysis

When entering a new patient into SCMO, after activating the program, the first step is

search the existing patients using the patient's name.

The appointment book can be searched by

specific appointment time specific providers specific exam rooms

Many medical software systems are moving away from narrative-type notes to templates and ______________.

structured data

Documentation that uses controlled vocabulary via preloaded data, drop-down menus, radio buttons, and sentence builders is known as:

structured data entry

Which of the following forms of information are considered administrative information?

superbills, day sheets, appointment history, and patient correspondence

Letters in EHR systems can be prepared from __________, which are electronic documents that have a basic format in which the required information can be entered.

templates

Maintaining the EHR is the responsibility of the:

the entire office