Electronic Health Records Wyma Ch.12 Full Test Bank

Student name:__________

1) Although implementing EHR systems can be expensive, the electronic record is quickly becoming the healthcare provider’s most important business and __________ record.

2) Medical information that is gathered in a manner that conforms to nationally recognized interoperability standards that can be used by members of more than one healthcare organization is called an electronic __________.

3) According to the National Alliance for Health Information Technology, a(n) __________ record is a computerized record of health-related information for an individual patient that is created, compiled, and managed by providers and staff members located within a single healthcare organization.

4) An electronic version of a patient’s comprehensive medical history and lifelong health record that is collected and maintained by the individual patient is a(n) __________ record.

5) Protected health information (PHI) in a patient’s personal health record is covered by __________ laws and cannot be disclosed without the patient’s express written permission, unless allowed by federal or state statute.

6) The primary reason most providers give for not implementing electronic records in their offices is __________.

7) EHRs allows healthcare providers to __________ electronic records at various locations, including the laboratory, pharmacy, and medical records department.

8) Electronic records provide security through special user names and __________ for each individual entering the records.

9) An EHR function that can alert staff members about patients who are due for yearly checkups and patients who require follow-up care uses computerized records as __________ files.

10) Some hospitals have begun to use electronically scanned images of patient __________ or photos to keep track of records, which can help cut down on insurance fraud.

11) EHR programs can be __________ to suit specific specialties and styles in a medical office.

12) Many EHR programs have an online insurance __________ function that allows you to check the patient's insurance coverage before performing a procedure.

13) The experienced coder should perform random internal coding __________ several times a year to ensure that coding is being performed correctly, even when an electronic coding program is used.

14) Most EHR programs allow electronic transmission of __________ from a patient's PCP to both the managed care insurance program and the specialists the patient needs to see.

15) The __________ in an EHR program can produce lists of patient statistics, demographics, accounts receivable, accounts payable, and many other useful items.

16) Virtually all EHR programs include electronic __________ writers because Medicare and Medicaid offer e-prescribing incentives.

17) A patient __________ provides patients with online access to routine EHR information and allows patients to perform tasks such as making an appointment or accessing a child's immunization record.

18) When medical records are kept electronically, it is essential that the facility have policies in place to ensure __________ and confidentiality of records.

19) Careful key entry is essential to maintaining __________ electronic health files, to protect both the patient and the medical office.

20) The difference between electronic medical records and electronic health records is that electronic health records conform to nationally recognized __________ standards.

21) To correct a mistake in an electronic health record, you must create a(n) __________ to the original, incorrect information.

22) When you are using an EHR to take notes during a patient interview, your main focus should be on the __________.

23) To help keep electronic records secure, you should secure the computer that maintains the electronic records and keep a(n) __________ of the electronic files.

24) Many EHR programs provide "check offs" or __________ that allow a medical office to customize the software with a few simple clicks of the mouse.

25) EHR programs that include medical coding software usually include a patient __________ component also, allowing the administrative staff to produce a statement for the patient after the insurance carrier has paid the claim.

26) Electronic prescriptions can be printed at the medical office and given to the patient or transmitted directly to the __________.

27) Many EHR programs include __________ programs for labs, X-rays, and other diagnostic and therapeutic services that allow orders to be submitted to the lab or office electronically at the time the patient appointment is made.

28) To help reassure others about EHR confidentiality and security, you should never display __________ about the new program, even when things go wrong while you are using the system.

29) One advantage of an EHR system is that electronic health records can be used during __________ so that several healthcare professionals in different locations can view the record simultaneously.

30) When you are creating a new patient record, you must be careful to enter the patient's name in the correct __________ so that the software "files" the electronic record correctly.

31) Electronic health record programs that have numerous capabilities in addition to creating and storing medical records are often referred to as __________.

32) The American Recovery and Reinvestment Act (ARRA) became law in 2009 because of concerns of possible data breaches with EHR. Part of this act includes __________, which is described as “HIPAA on steroids” because it greatly expands HIPAA compliance regulations.

33) The goals of __________ as they pertain to the EHR include better clinical outcomes, improved population health outcomes, increased transparency and efficiency, empowered individuals, and more robust research data on health systems.

34) A(n) __________ scheduling system can lock out selected appointment slots for various purposes and can provide the provider with a variety of reports that can help improve efficiency.

35) What percentage of the U.S. gross national product is accounted for by healthcare costs?

A) 5%
B) 10%
C) 17.8%
D) 20%
E) 25%

36) Which of the following was not a reason for development and promotion of electronic medical records?

A) increasing need for coordination of care
B) increasing age of the general population
C) paper medical records could no longer meet patients' needs
D) rising healthcare costs
E) increase in medical errors

37) Communication problems that contribute to medical errors in a medical facility include all of the following except __________.

A) mislabeled laboratory orders
B) mishandled patient messages
C) unreadable information in a patient's record
D) misfiled paper records
E) poor telephone etiquette

38) The goal of the presidential executive order signed in August 2006 was to give most Americans access to electronic health records by the year __________.

A) 2007
B) 2009
C) 2012
D) 2014
E) 2018

39) A patient's personal health record is owned by the __________.

A) patient
B) healthcare provider
C) medical practice
D) state government
E) federal government

40) Which of the following is a true statement about a patient's personal health record (PHR)?

A) PHR files are legal documents and are regulated by federal laws.
B) PHR data are entered by healthcare professionals or their staff.
C) PHRs may be stored and maintained on secure Internet sites.
D) PHR data usually can be disclosed without the patient's written permission.
E) PHR files contain treatment information related to only one provider.

41) Which stage of "meaningful use" of EHRs for Medicare and Medicaid patients includes documenting the percentage of visits, diagnoses, prescriptions, immunizations, and other pertinent health information electronically?

A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
E) Stage 5

42) Which of the following is mandated in Stage 2 of "meaningful use" of EHRs for Medicare or Medicaid patients?

A) accessing comprehensive patient data
B) enrolling patients in PHR
C) improving population health
D) sending and receiving clinical information electronically
E) participating in clinical decision support for national high-priority conditions

43) Which of the following is an advantage of EHRs?

A) patient concern for privacy
B) staff training
C) need for IT staff
D) legibility of records
E) software upgrades

44) Which of the following is a disadvantage of using an electronic scheduler?

A) Multiple users may use it at any time.
B) You can keep a list of patients who want earlier appointments.
C) You can search for appointments by appointment type needed.
D) You must look at each page to find a patient's forgotten appointment.
E) If the computer is down, the day's schedule is not accessible.

45) Dr. Hillman broke his leg while he was on vacation last week. His office has fully implemented EHR, so he plans to work from home part of the time. He will go into the office only as necessary to see patients. Which of the following is not possible for Dr. Hillman using the EHR system?

A) access patient records from his home computer
B) participate in a teleconference about a patient while viewing the patient's EHR
C) update patient files from his home computer
D) diagnose software problems on his home computer
E) save a patient's record to the central office computer

46) Which of the following is not likely to be a required field in your EHR software's form to be completed for each new patient?

A) patient name
B) insurance information
C) patient driver's license
D) next of kin
E) patient address

47) Generally, once an entry in an electronic health record is saved, a correction is made by __________.

A) adding an addendum
B) highlighting the error and placing a comment
C) deleting the error
D) striking through the error and adding initials
E) printing the page, correcting the error, and scanning the page

48) When information such as the result of a laboratory test is entered into a patient's EHR, the information is available for viewing __________.

A) immediately
B) the morning of the next business day
C) within two days
D) within one week
E) within 10 business days

49) How many identifiers are required to correctly identify a patient's EHR?

A) 1
B) at least 2
C) at least 3
D) at least 4
E) none

50) How often should passwords be changed in the EHR system?

A) after each use
B) at the end of every day
C) as directed by the healthcare facility policies
D) each time you allow someone else to use it
E) never

51) Which function of EHR programs allows the staff to make appointments for patients?

A) tickler file
B) electronic scheduler
C) billing and coding software
D) referral management
E) report generator

52) Which of the following is a disadvantage of using an electronic scheduler?

A) Multiple users may use it at any time.
B) You can keep a list of patients who want earlier appointments.
C) You can search for appointments by appointment type needed.
D) You must look at each page to find a patient's forgotten appointment.
E) If the computer is down, the day's schedule is not accessible.

53) Many EHR programs can verify a patient’s insurance coverage and simultaneously capture the patient’s __________.

A) demographic information
B) banking information
C) next of kin
D) next appointment date
E) financial status

54) If an EHR's coding software detects a charge that does not match a diagnosis code, it may __________.

A) refuse to process the file
B) produce a flag to alert the medical office
C) process the coding improperly
D) bill the patient erroneously
E) cause the computer to crash

55) In this morning's monthly financial status meeting, the office manager asked Cheryl for an analysis of how much revenue is generated by each of several procedures that are commonly performed in the medical office. To accomplish this in the most accurate and efficient manner, Cheryl should ____.

A) survey the patients who had the procedures
B) ask the healthcare providers who performed the procedures
C) use the EHR software's report generator
D) keep a checklist at the medical assistant's desk
E) search through patient files individually

56) At the provider’s request, Tony is attempting to enter a prescription for Mrs. Johnson for her high blood pressure. The EHR system keeps reporting an error: Incompatible medication. What might this mean, and what should Tony do about it?

A) The medication is not yet entered into the EHR system, so Tony should add it before entering the prescription.
B) The medication Tony is trying to enter has not yet been approved by the FDA, so he should enter another drug instead.
C) Tony misspelled the name of the medication, so he should check the spelling and try again.
D) Mrs. Johnson is either allergic to the medication or is taking another medication that interacts with it; Tony should consult the healthcare provider.
E) The medication is not on Mrs. Johnson's insurance list of covered medications; he should enter another drug instead.

57) Which of the following is not an advantage of the integration of ancillary programs for labs and other diagnostic and therapeutic services with an EHR system?

A) Orders can be submitted to the lab at the time the patient appointment is made.
B) Test results are transmitted to the healthcare provider's office as soon as they are available.
C) The patient and practitioner do not have to wait as long for test results.
D) Results can be faxed, scanned, or e-mailed as necessary.
E) Patients do not have to wait as long for lab or diagnostic appointments.

58) Many offices and EHR systems today allow patients to access and interact with certain parts of their EHR by providing a patient __________ to the system.

A) portal
B) password
C) key
D) code
E) admission

59) The greatest concern of electronic health records is __________.

A) computer network crashes
B) protecting the confidentiality of patient records
C) the retraining needed for medical staff
D) lack of access to paper medical records
E) lost or misfiled electronic records

60) Which of the following is not an acceptable method of reassuring patients and other staff members about EHR confidentiality and security?

A) Never display negativity about the EHR system.
B) Explain that patients can view a list of people who have accessed their information.
C) Explain the security systems in place in the medical office.
D) Show patients that anyone can view their medical information.
E) Create a pamphlet or flyer to explain the system to patients.

61) Like the rest of the office staff, Barry is still learning how to use the new EHR system installed in the medical office. He is with a patient and is attempting to document the patient's chief complaint in the EHR system, but he cannot get the system to accept the information. What should Barry do?

A) Tell the patient the new system is causing disruptions throughout the office.
B) Ask the patient to wait while he tries repeatedly to get the system to work.
C) Call the practitioner into the exam room to help him enter the information.
D) Skip this step and tell the patient the practitioner will be in shortly.
E) Document the patient's chief complaint on paper and enter it later into the EHR system.

62) Which type of electronic record is owned and maintained by the patient?

A) PHR
B) EMR
C) MRI
D) EHR
E) PIR

63) In order to find out which patients are not paying their office claims and statements promptly, you could ask the EHR report generator to create a(n) __________ report.

A) demographics
B) patient statistics
C) office statistics
D) accounts receivable
E) aging

64) The access codes that allow users to enter patient records in an EHR system insert a(n) __________ in the medical record, so that office administration can tell who is accessing each medical record.

A) red arrow
B) digital flag
C) date and time stamp
D) audio clip
E) byline

65) Who enters the data into a personal health record (PHR)?

A) practitioner
B) patient
C) medical assistant
D) physician assistant
E) insurance company

66) Angie is a new patient at Dr. Vander's office. She has an ear infection and the practitioner is prescribing an antibiotic. The medical office uses an EHR system and wants to transmit her prescription directly to Angie's pharmacy. She filled out the standard patient information sheet, but unfortunately, she cannot remember the name or phone number of her pharmacy. What should Dr. Vander's office do?

A) Refuse to provide the prescription.
B) Write the prescription by hand on a piece of scrap paper.
C) Tell Angie to go home, find her pharmacist's name and number, and come back.
D) Print the prescription from the EHR software.
E) Document that the prescription could not be given due to lack of information.

67) Common abbreviations are often used in the electronic health records. What does the abbreviation SX stand for?

A) size
B) symptoms
C) social history
D) status
E) subject’s history

68) Medical errors are somewhere between the 3rd and 8th leading cause of death for hospitalized patients. Most of these errors can be traced to all of the following communication problems except __________.

A) misfiled paper records
B) mishandled patient messages
C) information that is written in blue ink in a paper medical record
D) mislabeled laboratory orders
E) unreadable prescription orders

69) Which organization has defined the terms electronic medical record and electronic health record?

A) HIPAA
B) HITECH
C) NAHIT
D) ARRA
E) GINA

70) In order to find patient demographic information, you could ask the EHR report generator to create any of the following reports, except.

A) insurance information
B) marital status
C) phone
D) address
E) aging