EHR Final 7-12

What is a Problem List?
An up-‐to-‐date list of the diagnoses and
conditions that affect a particular patient’s
care.
Which of the following would not appear on a problem list?
vital signs data
why would a primary care physician choose to add a problem to a pts problem list automatically?
when the physician has already confirmed a diagnosis for the pt.
Certain wellness conditions may be included as part of the problems list based on which pt info?
gender
you are creating a new encounter Mrs. shelly a longtime pt at your med. office when creating the new encounter note for this pt how can you compare info from Mrs. shellys previous encounters?
by clicking on the manage tab
what does the choosing “resolved” for a particular problem do automatically?
it sets appropriate default actions related to that person.
When using pt. management, how would a clinician indicate that the treatment plan for a specific pt problem was working?
the clinician would select well controlled from the problems list tab drop down list to record the status.
The process of comparing info such as a test results, over a period of time is called:
trending
before a provider writes a prescription for a pt he or she should always check:
allergies and medications
a lab order is marked “preliminary” this means that the:
results show an early indication of the test, but are not verified
what is a flow sheet?
A feature of the software that presents
which of the following is considered an advantage of a flow sheet?
it allows findings from any previous encounter to be cited into the current note.
jared peters has type 2 diabetes, hypertension, and a new diagnosis od macular degeneration. when his provider sees jared during an encounter, which of the following is the most likely scenario?
the macular degeneration flow sheet will not have columns for previous encounters.
you have invoked a flow sheet from a form using the student edition software. what does this mean?
the first column of the flow sheet is populated by findings pertinent to the selected form.
what does the cite feature do?
it brings forward findings from a previous encounter into the current encounter.
a pt has had a new cholesterol test result, and you are using the cite window to record this finding. you should remember that:
the data you enter will post to the current pt encounter.
you want to create a flow sheet that is based on a specific problem. to accomplish this task, what do you need to do first?
click on the manage tab
the line drawing tool would be most useful to accomplish which of the following when annotating a drawing within the ehr?
connect elements on the drawing.
an EHR system that allows a clinician to select findings related to a sprained ankle by viewing an anatomic illustration of the foot would be useful because:
it allows the clinician to zero in on the appropriate findings quickly.
Janice made an apt for her regular mammogram. this is an example of?
preventative screening.
Jeremy’s pediatrician notes that he is in the 75th percentile for his height. What does this mean?
Jeremy is shorter than 25% of the reference population for boys.
Joyce has been keeping a graph of her blood pressure at home for a few months. This means that Joyce:
is better able to tell if her current treatment is effective.
which of the following would not be considered an advantage of giving a pt a copy of an exam note at the end of an office visit?
a pt who has a copy of an exam note will have an easier time filling a prescription than a pt who does not have that info.
which of the following is true about childhood immunizations?
Some vaccines must be given more than one at a time.
Mr. Juarez signed an authorization form giving his cardiologist permission to use his PHI for a research study. What does this mean?
Mr Juarez understands the reason his cardiologist wishes to use his PHI.
Mrs. smothers. a resident in an assisted living facility, wants to review her med. record. what does this request mean to the facility?
they may charge the resident for the costs associated with supplying the record.
Which of the following gov’t agencies is charged with enforcing the privacy rule?
OCR
Which of the following is the first step when a health care provider begins implementation of the administrative safeguards portion of the security rule?
The Security management process,
Which of the following best describes a security official?
An employee who has overall responsibility for the HIPAA security rule.
Which of the following would not be a recommended way to prevent unauthorized individuals from accessing an EHR system?
Storing PIN info in a file on your computer.
Which of the following statements is true about digital signatures?
Digital signatures require the use of cryptography and PKI.
What does the term user authentication mean in relation to criteria for electronic signatures?
That the person who receives the document can verify that the document was signed by a real person.
Which of the following would most likely be considered a breach of PHI?
Business associate of a health car provider uses PHI to find out the addresses of pts who live in a certain region.
Which of the following is an example of decision support in relation to an EHR system?
Links to specific protocols, case study results or guidelines.
Jorge is a physician at a busy practice w/I a large suburban area; he is on call for emergencies one night each week and needs access to the records of all the pts seen by his practice. Which of the following will Jorge need for direct access to his office computer while away from his med. office?
VPN
Which of the following would be an example of a store and forward telemedicine?
Voicemail message to a referring physician.
Dana has sent an email to her provider with a question about a recent blood work results. According to the HIPAA security rule, Dana’s provider must:
not send any PHI if replying by email.
An E- visit would work best in which of the following situations?
Treating a pt who has seasonal allergies.
Ideally a pts PHR contains info for the persons ___.
Lifetime.
Typically, an email communication btwn a pt and a provider:
is not reimbursed as an E&M
Billing for certain services is based on the ___
Diagnosis code
Which of the following E&M code level has the lowest “allowed payment” amount?
level 1
Which of the following is considered one of the key components of a patient encounter in determining the level of an E&M service?
Medical decision making
The ____ level of the ROS w/I the E&M calculator requires that the physician has reviewed at least 10 organ systems that are directly related to the problems.
complete
a physician has advised her pt to take ibuprofen to manage pain from a sprained ankle. Into which risk level w/I the med decision making component of E&M calculator would this management option fail?
Low
Which of the following is not part of the face to face time?
calling a pt to remind him of an appt.
most health are facilities that use an EHR system that is integrated with billing software:
hold codes as pending until they are reviewed
How is the overall MDM calculated?
It is based on the highest levels of any two of the three elements.
An obstetrician orders a fetal contraction stress test for a pt. this procedure would fall under the ___ level of risk:
moderate
___ may be compared to the first automobiles bc in the early stages of new technology ppl tend to look at things the old way.
the electronic health record.