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Electronic Health Records: Understanding And Using Computerized Medical Records, 3rd Edition Test Bank

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    Exam Name___________________________________ MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) Which of the following statements is true? 1) A) A patient's account number is always the same as his or her patient ID. B) A guarantor is a person who is responsible for paying any portion of a healthcare bill that is not covered by insurance. C) A patient must be the guarantor of his or her own account with a healthcare provider. D) A patient cannot be the beneficiary of a health plan unless he or she is also the policy holder. Answer: B Explanation: A) B) C) D) 2) When patients sign an assignment of benefits document, they 2) A) are waiving their privacy rights under HIPAA B) are authorizing their health plan to pay the healthcare provider directly. C) are agreeing to serve as guarantor of their account with a healthcare provider. D) are indicating that their health insurance coverage extends to their dependents. Answer: B Explanation: A) B) C) D) 3) According to the IOM, the ultimate goal of computerizing medical records is: 3) A) To safeguard the privacy of patients' medical information. B) To create a longitudinal log of patients' medical encounters. C) To simplify result and order management for medical practitioners. D) To improve the delivery of safe, quality care focused on patients' health. Answer: D Explanation: A) B) C) D) 1

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    4) In which of the following scenarios is the EHR functioning in an order management capacity, as described by the IOM? 4) A) After a patient undergoes laboratory testing to determine his serum cholesterol levels, the electronic health records system automatically emails him a copy of the test results. B) Each week, a hospital's electronic health records system transmits information regarding all new cases of reportable diseases to the county health department. C) Whenever a particular drug is recalled, a practice's electronic records system generates a list of all patients who are taking this medication so they can be immediately notified of the recall. D) When a physician types the prescribed dose of a particular medication into a patient's electronic health record, the system generates a warning stating that this dose is dangerously high and may have been entered incorrectly. Answer: D Explanation: A) B) C) D) 5) Which of the following statements is accurate? 5) A) The EHR includes information on a patient's physical health but not his or her mental health. B) The EHR focuses only on information related to patients' past and present health. C) The federal government proposed its own definition of EHR in the Health Insurance Portability and Accountability Act. D) The EHR encompasses not just stored data, but also the functional benefits of having such data Answer: D Explanation: A) B) C) D) 6) A particular healthcare appointment lasts 60 minutes total and requires 75% effort on the part of the physician. Which of the other appointments listed below could be scheduled during the same period? 6) A) An appointment that lasts 30 minutes and requires 50% effort B) An appointment that lasts 60 minutes and requires 30% effort C) An appointment that lasts 45 minutes are requires 40% effort D) An appointment that lasts 25 minutes and requires 85% effort Answer: A Explanation: A) B) C) D) 2

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    7) Which federal regulatory body is charged with developing a strategic plan to guide the "nationwide implementation of interoperable health information technology in both the public and private healthcare sectors"? 7) A) ONC B) CMS C) HITECH D) AHRQ Answer: A Explanation: A) B) C) D) 8) Which of the following statements is true? 8) A) Point - of - care documentation often results in decreased accuracy of patient data. B) Point - of - care documentation offers no clear benefit with regard to patient education. C) Point - of - care documentation lowers the overall cost of healthcare delivery. D) Point - of - care documentation is less efficient than traditional documentation but leads to increased patient compliance. Answer: C Explanation: A) B) C) D) 9) One benefit of electronic charting (as compared to paper charting) is that 9) A) it permits only physicians and registered nurses to view a patient's chart. B) it permits multiple providers to access a patient's chart at the same time. C) it eliminates the need for providers to exercise clinical judgment. D) it decreases the need for patient counseling and education. Answer: B Explanation: A) B) C) D) 10) Physicians who use electronic rather than paper charting typically 10) A) spend less time revising prescriptions. B) spend more time determining and documenting billing codes. C) spend more time finalizing exam notes at the end of the workday. D) have less time available for patient education and counseling. Answer: A Explanation: A) B) C) D) 3

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    11) Which of the following pieces of information would not be appropriate to record during the patient registration process? 11) A) HIPAA privacy preferences B) Emergency contact information C) Percent effort for an appointment D) Preferred language Answer: C Explanation: A) B) C) D) 12) According to the IOM, all of the following are core functions of an electronic health record except : 12) A) Enhancing patient support and education B) Decreasing outside access to patients' health information C) Increasing the efficiency of administrative processes D) Improving order management Answer: B Explanation: A) B) C) D) 13) As compared to an outpatient chart, an inpatient chart likely 13) A) covers a longer span of time. B) has fewer people accessing it. C) contains a greater quantity of data. D) consists largely of the physician's exam notes. Answer: C Explanation: A) B) C) D) 14) Which of the following is a societal trend that has helped contribute to increased use of EHR? 14) A) Increased specialization among medical care providers B) Rising public concern about the security of electronic data C) Patient reluctance to rely on health information obtained through the Internet D) Americans' decreasing tendency toward relocation Answer: A Explanation: A) B) C) D) 4

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    15) How did the HITECH Act of 2009 help promote EHR adoption? 15) A) It authorized the CMS to make incentive payments to consumers who select healthcare providers that use a certified EHR. B) It authorized the ONC to make incentive payments to consumers who select healthcare providers that use a certified EHR. C) It authorized the ONC to make incentive payments to healthcare providers that use a certified EHR. D) It authorized the CMS to make incentive payments to healthcare providers that use a certified EHR. Answer: D Explanation: A) B) C) D) 16) Information regarding a patient's self - described symptoms would be recorded in what portion of the chart? 16) A) Plan B) Objective C) Assessment D) Subjective Answer: D Explanation: A) B) C) D) 17) Which of the following is an example of point - of - care documentation? 17) A) A physician records notes on a patient encounter shortly after the patient leaves the office. B) A nurse enters a patient's vital signs while standing at the bedside. C) A nurse enters patient encounter notes at the end of a shift. D) A physician reviews test results prior to a patient's office visit. Answer: B Explanation: A) B) C) D) 18) As compared to paper medical records, electronic health records offer 18) A) similar levels of portability. B) decreased legibility. C) increased liability. D) increased searchability. Answer: D Explanation: A) B) C) D) 5

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    19) Which of the following is not a social force that is driving the adoption of EHR? 19) A) Consumers' increasing expectation that health information be available both quickly and securely over the Internet B) Patients' increasing tendency to remain in the care of a single healthcare provider for a period of several years or more C) Widespread concern about the number of preventable medical errors that occur each year in the United States D) Employer and insurer concerns about the connection between poor quality care and rising healthcare costs Answer: B Explanation: A) B) C) D) 20) Which of the following statements is accurate with regard to patient charts? 20) A) An outpatient chart usually focuses on treatment of a specific ailment for which the patient has sought care. B) A unique inpatient chart is created for each of a patient's hospital stays. C) An outpatient chart consists primarily of the physician's orders and nurses' notes indicating the patient's response. D) An inpatient chart contains less patient data because it covers a shorter period of time. Answer: B Explanation: A) B) C) D) 6

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    Answer Key Testname: C1 1) B 2) B 3) D 4) D 5) D 6) A 7) A 8) C 9) B 10) A 11) C 12) B 13) C 14) A 15) D 16) D 17) B 18) D 19) B 20) B 7

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    Exam Name___________________________________ MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) When entering a test order into a patient's EHR, a clinician receives an alert indicating that an ABN is required. In this scenario, the clinician must 1) A) notify the patient that the test will be fully covered by Medicare, then have the patient sign a form indicating that he has received this information. B) notify the patient that Medicare requires a second follow - up test also be performed, then have the patient sign a waiver indicating that he has been informed of this requirement. C) notify the patient that the test will not be covered by Medicare, then have the patient sign a waiver indicating that he has received this information and agrees to pay for the test. D) notify the patient that Medicare considers this test unnecessarily dangerous, then have the patient sign a form indicating that he understands the associated risks. Answer: C Explanation: A) B) C) D) 2) Which of the following statements is true with regard to patient - entered data? 2) A) Patients who enter their own data are often better prepared for their visits with clinicians. B) Patient - entered data tends to not accurately reflect a patient's complaints. C) Use of patient - entered data offers no time savings to clinicians. D) Patient - entered data does not require clinician review prior to being merged into the EHR. Answer: A Explanation: A) B) C) D) 3) Medcin differs from SNOMED - CT in that 3) A) it contains only two types of semantic relationships: Is - A and Attribute . B) it was designed to classify medical information for research purposes. C) its nomenclature is purely a codified list of terms. D) it was originally developed for point - of - care use by clinicians. Answer: D Explanation: A) B) C) D) 4) Which of the following EHR code sets is used to codify the discrete elements of nursing practice? 4) A) RxNorm B) LOINC C) CCC D) UMLS Answer: C Explanation: A) B) C) D) 1

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    5) Which of the following is a major benefit of codified EHR? 5) A) Use of codes eliminates the need for fielded data in patients' medical records. B) Use of codes allows each clinician to develop a unique system for indicating specific findings or treatments. C) Use of codes allows for more precise identification of a clinician's findings. D) Use of codes eliminates the need for digital image or text data in patients' medical records. Answer: C Explanation: A) B) C) D) 6) When entered into an EHR, text - based lab results 6) A) are harder to search than image - based lab results but easier to analyze than coded lab data. B) are easier to search than image - based lab results but more difficult to analyze than coded lab data. C) are harder to search than coded lab data but easier to use in trend analysis. D) are easier to search than coded lab data but harder to use in trend analysis. Answer: B Explanation: A) B) C) D) 7) Which of the following statements is true with regard to the capture and recording of EHR data? 7) A) Digital images are rarely included in a patient's EHR. B) Modern computer systems eliminate the need for human involvement in the scanning and cataloging of EHR data C) It is preferable to import word processing files rather than print and scan them. D) Text data must be codified before it can be imported into an EHR. Answer: C Explanation: A) B) C) D) 8) Within SNOMED - CT, which type of relationship connects concepts from two different hierarchies? 8) A) An Attribute relationship B) A Category relationship C) A Link - To relationship D) An Is - A relationship Answer: A Explanation: A) B) C) D) 2

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    9) A protocol is 9) A) a list of medications that are covered by a particular health insurance plan. B) a standard plan of therapy that has been established for a particular condition. C) a set of instructions for performing a specific action within an EHR system. D) a set of standard warnings associated with a specific medication. Answer: B Explanation: A) B) C) D) 10) Which of the following code sets is primarily used to record information related to laboratory test orders and results? 10) A) CCC B) LOINC C) Medcin D) SNOMED - CT Answer: B Explanation: A) B) C) D) 11) Use of a codified EHR 11) A) makes it more difficult for clinicians to identify trends in a patient's health. B) makes it harder for clinicians to consult drug formularies prior to writing prescriptions. C) decreases the likelihood that patients will not receive recommended preventive screenings. D) complicates the process of drug utilization review. Answer: C Explanation: A) B) C) D) 12) Which of the following functions would not be part of a computerized DUR program? 12) A) Checking a patient's prescription record to determine whether there is the potential for any drug - drug interactions B) Comparing a patient's prescription record against a list of similar drugs to determine whether cheaper medication alternatives exist C) Determining whether the prescribed dose of a drug falls within recommended guidelines D) Reviewing a patient's records for any allergies that may be aggravated by a new drug Answer: B Explanation: A) B) C) D) 3

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    13) In which of the following scenarios is the EHR system functioning in a decision - support capacity? 13) A) An EHR system links a physician to the latest evidence - based guidelines for treating a particular disease. B) An EHR system notifies a physician that an ABN is required for a particular procedure. C) An EHR system reminds a nurse that she has forgotten to obtain all of a patient's vital signs during an office visit. D) An EHR system automatically emails a patient a copy of her latest lab results. Answer: A Explanation: A) B) C) D) 14) Most EHR systems issue immunization alerts based on 14) A) recommended schedules developed by the CDC and the state department of health. B) the patient's preferred vaccination timeline. C) the individual clinician's preferred vaccination timeline. D) recommended schedules developed by the World Health Organization. Answer: A Explanation: A) B) C) D) 15) A(n) ________ is a message or reminder that is automatically generated by an EHR system. 15) A) alert B) caution C) condition D) warning Answer: A Explanation: A) B) C) D) 16) Which of the following statements accurately describes coded data? 16) A) Coded data is a form of discrete data but not a form of fielded data. B) Coded data is the most difficult type of data for a computer to search and retrieve. C) Coded data is usually obtained by importing text files from outside sources. D) Coded data is fielded data that contains codes in addition to or in place of descriptive text. Answer: D Explanation: A) B) C) D) 17) ________ is the electronic transmission of healthcare - related data among facilities, health information organizations, and government agencies. 17) A) HIE B) DICOM C) HL7 D) CDISC Answer: A Explanation: A) B) C) D) 4

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    18) Two critical components of health maintenance are 18) A) lab result tracking and preventive care screening. B) immunizations and drug utilization review. C) preventive care screening and immunizations. D) drug utilization review and lab result tracking. Answer: C Explanation: A) B) C) D) 19) What are the three main forms of EHR data? 19) A) Discrete data, diagnostic images, and scanned documents B) Digital images, text files, and discrete data C) Digital images, fielded data, and coded data D) Diagnostic images, scanned documents, and text files Answer: B Explanation: A) B) C) D) 20) In which of the following scenarios is the employee cataloging an image in an EHR? 20) A) An employee uses a scanner to create a digital version of a printed document, then imports the digital file into a patient's EHR. B) An employee assigns descriptive keywords to a image file that has been imported into a patient's EHR. C) An employee deletes a digital image from a patient's EHR and replaces it with textual data that conveys the same information. D) An employee receives a digital image from a patient's radiologist, then imports the image file into the patient's EHR. Answer: B Explanation: A) B) C) D) 5

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    Answer Key Testname: C2 1) C 2) A 3) D 4) C 5) C 6) B 7) C 8) A 9) B 10) B 11) C 12) B 13) A 14) A 15) A 16) D 17) A 18) C 19) B 20) B 6

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    Exam Name___________________________________ MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) Clicking the View button on the toolbar lets you choose from what three display options? 1) A) Expanded view, concise view, and outline view B) Expanded view, condensed view, and heading view C) Entry view, expanded view, and heading view D) Entry view, concise view, and outline view Answer: D Explanation: A) B) C) D) 2) Which of the following vital signs has more than one possible unit of measure? 2) A) Blood pressure B) Heart rate C) Temperature D) Oxygen saturation Answer: C Explanation: A) B) C) D) 3) Which of the following statements is true with regard to setting an encounter date in the Student Edition? 3) A) When typing an encounter date into Quippe, you must use the format YY/DD/MM. B) When you create an encounter in Quippe, the month, day, and year automatically default to your computer's date settings. C) When entering an encounter date in Quippe, there is no need to type a slash between the month and day or between the day and year. D) There are three different methods for entering an encounter date in Quippe. Answer: B Explanation: A) B) C) D) 1

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    4) To remove a clinical concept from an encounter note, you should 4) A) click on the concept within the appropriate section of the workspace, then click the blue Quippe icon button and select Remove from the drop - down menu that appears. B) double - click on the concept within the appropriate section of the workspace, then select Remove from the drop - down menu that appears. C) click on the concept within the appropriate section of the workspace, then click the Tools button and select Delete from the drop - down menu that appears. D) click on the concept within the appropriate section of the workspace, then click the Actions button and select Delete from the drop - down menu that appears. Answer: D Explanation: A) B) C) D) 5) Clicking the Tools button allows you to 5) A) access the E&M Calculator. B) change the workspace display. C) open the Quippe application menu. D) search the Medcin knowledge base. Answer: A Explanation: A) B) C) D) 6) Clinical concepts used in the Plan section of a SOAP encounter note are located in which Medcin nomenclature domain? 6) A) Therapy B) Physical examination C) Symptoms D) Diagnoses, syndromes and conditions Answer: A Explanation: A) B) C) D) 7) In the Student Edition software, 7) A) an unentered clinical finding is considered normal. B) a negative clinical finding is considered normal. C) an unentered clinical finding is considered abnormal. D) a positive clinical finding is considered normal. Answer: B Explanation: A) B) C) D) 2

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    8) To generate a printable PDF of an encounter note, you should 8) A) click the Actions toolbar button, then select Export Data from the list of available options. B) click the blue Quippe icon button, then select Export Data on the drop - down menu that appears. C) click the Actions toolbar button, then select Create PDF from the list of available options. D) click the blue Quippe icon button, then select Create PDF on the drop - down menu that appears. Answer: D Explanation: A) B) C) D) 9) The Quippe Student Edition software uses which standard EHR nomenclature? 9) A) LOINC B) SNOMED - CT C) CCC D) Medcin Answer: D Explanation: A) B) C) D) 10) Details are added to a finding via a pop - up window that is invoked by either 10) A) clicking the Tools button on the toolbar or double - clicking on the finding. B) clicking the Actions button on the toolbar or double - clicking on the finding. C) clicking the Actions button on the toolbar or right - clicking on the finding. D) clicking the Tools button on the toolbar or right - clicking on the finding. Answer: C Explanation: A) B) C) D) 11) In the Student Edition, to record a clinical concept as a finding, you should 11) A) designate the concept as either positive or negative. B) leave the concept in the unentered state. C) drag the concept from the Clinical Concept menu to the Findings window. D) type the name of the concept into the workspace pane. Answer: A Explanation: A) B) C) D) 12) If you wanted to indicate that a particular clinical concept was worsening, you would do so using which field in the Details pop - up window? 12) A) Status B) Modifier C) Duration D) Onset Answer: A Explanation: A) B) C) D) 3

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    13) Which of the following statements is accurate? 13) A) Information regarding a patient's chief complaint is usually entered by selecting one or more options from a clinical concept menu. B) A chief complaint field is rarely included in encounter templates because it is not part of the CMS recommended standard. C) The CMS requires that a chief complaint field be included in every encounter template. D) Information regarding a patient's chief complaint is usually entered by typing in a free - text note field. Answer: D Explanation: A) B) C) D) 14) How do you select a patient from the New Encounter window? 14) A) Scroll through the list of patients in the New Encounter window. Right - click on the name of the desired patient, then click Select on the drop - down menu that appears. B) Type the patient's name into the Search portion of the New Encounter window. When the patient's name appears in the Results box, double - click it with the left mouse button. C) Scroll through the list of patients in the New Encounter window. Click once on the name of the desired patient, then click OK. D) Type the patient's name into the Search portion of the New Encounter window. When the patient's name appears in the Results box, click it once, then select OK. Answer: C Explanation: A) B) C) D) 15) How do you add free text details to a finding? 15) A) Click on the clinical concept, then click the Actions button and select the Modify option from the drop - down menu. In the pop - up window that appears, type the free text into the Status field. B) Click on the clinical concept, then click the Actions button and select the Modify option from the drop - down menu. In the pop - up window that appears, type the free text into the Note field. C) Click on the clinical concept, then click the Actions button and select the Detail option from the drop - down menu. In the pop - up window that appears, type the free text into the Note field. D) Click on the clinical concept, then click the Actions button and select the Detail option from the drop - down menu. In the pop - up window that appears, type the free text into the Status field. Answer: C Explanation: A) B) C) D) 4

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    16) Which of the following measurements is always considered a vital sign? 16) A) Oxygen saturation B) Blood pressure C) Height D) Respiration rate Answer: D Explanation: A) B) C) D) 17) If a patient takes 18 breaths per minute, you should enter "18" in which field of the Vital Signs table in the patient's encounter note? 17) A) BR B) RR C) DBP D) PR Answer: B Explanation: A) B) C) D) 18) Which toolbar button is used to access and navigate the clinical concepts in the Medcin nomenclature? 18) A) Tools B) View C) Browse D) Actions Answer: C Explanation: A) B) C) D) 19) The Subjective section of a SOAP encounter note would include information from which Medcin nomenclature domains? 19) A) Physical Examination, Symptoms, and History B) Physical Examination and Tests C) Symptoms and History D) History and Physical Examination Answer: C Explanation: A) B) C) D) 5

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    20) To add information about a patient's exercise habits to an encounter note, you should 20) A) click the Browse button on the toolbar, then click the plus symbol next to Concepts, followed by the plus symbol next to History, the plus symbol next to Social history, and the plus symbol next to Habits. B) click the Search button on the toolbar, then click the plus symbol next to Concepts, immediately followed by the plus symbol next to History and the plus symbol next to Behavioral history. C) click the Search button on the toolbar, then click the plus symbol next to Concepts, immediately followed by the plus symbol next to History and the plus symbol next to Social history. D) click the Browse button on the toolbar, then click the plus symbol next to Concepts, immediately followed by the plus symbol next to History and the plus symbol next to Behavioral history. Answer: A Explanation: A) B) C) D) 6

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    Answer Key Testname: C3 1) D 2) C 3) B 4) D 5) A 6) A 7) B 8) D 9) D 10) C 11) A 12) A 13) D 14) C 15) C 16) D 17) B 18) C 19) C 20) A 7

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    Exam Name___________________________________ MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) When entering findings using the Yes/No style of check boxes, how would you indicate that a patient does not have a reaction to anesthetics? 1) A) Click on Y check box for reaction to anesthetics then use the word "no" as a modifier. B) Click on Y check box for reaction to anesthetics. C) Click on N check box for reaction to anesthetics. D) Leave the reaction to anesthetics line unmarked to indicate that there is no reaction Answer: C Explanation: A) B) C) D) 2) How does the Student Edition compare to Medcin - based EHR systems being used in medical facilities? 2) A) The nomenclature varies but the visual style is the same. B) The systems vary in visual style and nomenclature. C) Both have the same nomenclature and visual style. D) The visual style varies but the nomenclature is the same. Answer: D Explanation: A) B) C) D) 3) When using a text macro, what does it mean when portions of the text are highlighted? 3) A) They are fields for entering patient consent to procedures. B) Those findings are abnormal. C) They are fields for entering findings and details. D) Those findings are positive. Answer: C Explanation: A) B) C) D) 4) Blue text indicates that a finding is 4) A) normal. B) absent. C) present. D) abnormal. Answer: A Explanation: A) B) C) D) 1

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    5) How does one clear a prefix that has previously been entered? 5) A) Use the blank row in the drop - down list of the Prefix field of Entry Details. B) Erase the entire entry and re - enter with the correct prefix. C) Use the erase button under the Prefix field of Entry Details. D) Use the correct prefix under the Prefix field of Entry Details. Answer: A Explanation: A) B) C) D) 6) How is cigarette use reported? 6) A) By using a standard unit of packs per day and then the number of years B) By using a standard unit of pack - years C) By using drop - down menus to indicate length of time and quantity smoked D) By double - clicking on the finding of "cigarette use" Answer: B Explanation: A) B) C) D) 7) When using a text macro, how are findings within the macro entered? 7) A) A pop - up window allows all findings to be set at once. B) Each related group should be clicked on and set as a sub - set. C) Each one can only be set individually by browsing through the entire Medcin nomenclature. D) Findings cannot be entered within the text macro. Answer: A Explanation: A) B) C) D) 8) When entering findings using the two - button style, what is indicated by clicking the left - most button? 8) A) The finding is normal. B) The finding is absent. C) The finding is negative. D) The finding is abnormal. Answer: D Explanation: A) B) C) D) 2

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    9) When findings have three states, which of the following is not a correct match between state and color code? 9) A) Normal = blue B) Neutral = gray C) Abnormal = red D) Negative = yellow Answer: D Explanation: A) B) C) D) 10) A patient indicates that she has severe pain. Which of the following would be the next step after locating and selecting the finding for pain? 10) A) Right - click on pain, and then select the Details tab where the prefix is changed to severe. B) Left - click on pain, and then select the Details tab where the modifier is changed to severe. C) Left - click on pain, and then select the Details tab where the prefix is changed to severe. D) Right - click on pain, and then select the Details tab where the modifier is changed to severe. Answer: D Explanation: A) B) C) D) 11) Which of the following is a unique characteristic of the Tobacco and Alcohol Use sections? 11) A) Positive findings will result in free text boxes. B) Positive findings will turn purple. C) Positive findings will turn blue. D) Positive findings will result in an entry field for details. Answer: D Explanation: A) B) C) D) 12) How would you enter the finding that the patient smoked half a pack of cigarettes each day for 20 years? 12) A) 20 pack - years B) 5 pack - years C) 10 pack - years D) 1/2 pack per day per 20 years Answer: C Explanation: A) B) C) D) 3

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