Chapter 12
Electronic Health Records
Multiple Choice Questions
1. | What percentage of the U.S. gross national product is accounted for by healthcare costs?
|
2. | 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 |
|
3. | 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 |
|
4. | The goal of the presidential executive order signed in August 2006 was to give most Americans access to electronic health records by the year ____.
|
5. | A patient's personal health record is owned by the ____.
|
6. | 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. |
|
7. | Which step 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?
|
8. | Which of the following is mandated in Step 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 |
|
9. | The estimated cost for the initial establishment of an EHR program is ____ per full-time provider.
|
10. | The estimated maintenance cost for an EHR system is approximately ____ per year per full-time provider.
|
11. | Which of the following is an advantage of EHRs?
A. | Patient concern for privacy |
|
12. | Which of the following is a disadvantage of implementing an EHR system?
A. | Fewer lost medical records |
B. | Staff training requirements |
C. | Efficient transfer of records |
D. | Chart access for multiple users |
E. | Decreased storage needs |
|
13. | 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 |
|
14. | 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?
C. | Patient driver's license |
|
15. | Generally, once an entry in an electronic health record is saved, a correction is made by ____.
B. | highlighting the error and placing a comment |
D. | striking through the error and adding initials |
E. | printing the page, correcting the error, and scanning the page |
|
16. | When information such as the result of a laboratory test is entered into a patient's EHR, the information is available for viewing ____.
B. | the morning of the next business day |
E. | within 10 business days |
|
17. | How many identifiers are required to correctly identify a patient's EHR?
|
18. | How often should passwords be changed in the EHR system?
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 |
|
19. | Which function of EHR programs allows the staff to make appointments for patients?
C. | Billing and coding software |
|
20. | 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. |
|
21. | Many EHR programs can verify a patient’s insurance coverage and simultaneously capture the patient’s __________.
A. | demographic information |
|
22. | 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 |
|
23. | 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 physicians 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 |
|
24. | 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 physician. |
E. | The medication is not on Mrs. Johnson's insurance list of covered medications; he should enter another drug instead. |
|
25. | 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 physician's office as soon as they are available. |
C. | The patient and physician 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. |
|
26. | 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.
|
27. | 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 |
|
28. | 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 |
|
29. | 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 physician into the exam room to help him enter the information |
D. | Skip this step and tell the patient the physician will be in shortly |
E. | Document the patient's chief complaint on paper and enter it later into the EHR system |
|
30. | Which type of electronic record is owned and maintained by the patient?
|
31. | Dr. Ehrlinger and Dr. Copas are partners who own and operate a small medical practice in rural Kentucky. They are considering upgrading their practice to use electronic health records, but they are concerned about the costs involved. Including the initial startup cost and the estimated cost to maintain the system, how much will upgrading to an EHR system cost the practice in the next 5 years?
|
32. | 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.
|
33. | 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.
|
34. | Who enters the data into a personal health record (PHR)?
|
35. | Angie is a new patient at Dr. Vander's office. She has an ear infection and the physician 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 |
|
Fill in the Blank Questions
36. | The federal government requires that all health records become electronic for eligible Medicare providers, with very few exceptions, by the year ________.
________________________________________ |
37. | Although implementing EHR systems can be expensive, the electronic record is quickly becoming the physician's most important business and ________ record.
________________________________________ |
38. | 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 ____________.
________________________________________ |
39. | 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.
________________________________________ |
40. | 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.
________________________________________ |
41. | 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.
________________________________________ |
42. | The primary reason most providers give for not implementing electronic records in their offices is ________.
________________________________________ |
43. | EHRs allows healthcare providers to ________ electronic records at various locations, including the laboratory, pharmacy, and medical records department.
________________________________________ |
44. | Electronic records provide security through special user names and _________ for each individual entering the records.
________________________________________ |
45. | 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.
________________________________________ |
46. | 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.
________________________________________ |
47. | EHR programs can be ________ to suit specific specialties and styles in a physician's office.
________________________________________ |
48. | Many EHR programs have an online insurance ________ function that allows you to check the patient's insurance coverage before performing a procedure.
________________________________________ |
49. | 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.
________________________________________ |
50. | 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.
________________________________________ |
51. | The ________ in an EHR program can produce lists of patient statistics, demographics, accounts receivable, accounts payable, and many other useful items.
________________________________________ |
52. | Virtually all EHR programs include electronic ________ writers because Medicare and Medicaid offer e-prescribing incentives.
________________________________________ |
53. | 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.
________________________________________ |
54. | When medical records are kept electronically, it is essential that the facility have policies in place to ensure ________ and confidentiality of records.
________________________________________ |
55. | Careful key entry is essential to maintaining ________ electronic health files, to protect both the patient and the medical office.
________________________________________ |
56. | The difference between electronic medical records and electronic health records is that electronic health records conform to nationally recognized ________ standards.
________________________________________ |
57. | To correct a mistake in an electronic health record, you must create a(n) ________ to the original, incorrect information.
________________________________________ |
58. | When you are using an EHR to take notes during a patient interview, your main focus should be on the ________.
________________________________________ |
59. | To help keep electronic records secure, you should secure the computer that maintains the electronic records and keep a(n) ________ of the electronic files.
________________________________________ |
60. | Many EHR programs provide "check offs" or ________ that allow a physician to customize the software with a few simple clicks of the mouse.
________________________________________ |
61. | 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.
________________________________________ |
62. | Electronic prescriptions can be printed at the medical office and given to the patient or transmitted directly to the ________.
________________________________________ |
63. | 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.
________________________________________ |
64. | 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.
________________________________________ |
65. | 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.
________________________________________ |
66. | 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.
________________________________________ |
Multiple Choice Questions
67. | Common abbreviations are often used in the electronic health records. What does the abbreviation SX stand for?
|
68. | Medical errors due to communication problems are the __________ leading cause of deaths in the United States.
|
69. | Which organization has defined the terms electronic medical record and electronic health record?
|
Fill in the Blank Questions
70. | Electronic health record programs that have numerous capabilities in addition to creating and storing medical records are often referred to as __________________________.
________________________________________ |
71. | 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.
________________________________________ |
72. | 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.
________________________________________ |