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EHR
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EHR
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25 cards
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Questions
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Answers
1
When SOAP noting is used for documentation, where would find the procedures that were performed?
Plan
Assessment
Subjective
Objective
2
What is example of plan
legal documents
date night
Referral
clinical note
3
A patient who must have a procedure done that isn't covered by health insurance asks you what it will cost
Account ledger
Claims history
Progress note
Fee schedule
4
Which is part of Demographics ?
Name, DOB, address
Town, city, state
Consent Form
Progress note, clinicl portion
5
A patient who has a new diagnosis of hypertension asks you where they can find more information about this condition.
You can find a lot of information on the internet.
There are patient education materials that you can access patient portal
Social media has a lot of support groups for people with your diagnosis.
You can ask your provider at your next visit.
6
What is EHR ?
Electronic Health Record
Electronic Health Release
Electronic Hipaa Record
Electronic Help Record
7
Which of the following recorded data might be worn as a patient color coded wrist band?
Allergy
Account number
Medication
Patient name
8
E and M stands for ?
Evaluate and Misuse
Evolve and Management
Evaluate and Micromanage
Evaluate and Management
9
Coding bronchitis as pneumonia, or upcoding, is considered:
Neglect
Malpractice
Fraud
Abuse
10
Sending patient claim information electronically to the insurance company would be considered:
Improper use of the EHR
Internal use of the patient database
A violation of HIPAA
Transmitting patient data for external use
11
Diagnostic codes can be found in which manuals?
HCPCS
ICD
HIPAA
CPT
12
A patient calls asking for the date of their last tetanus shot. Where in the EHR would you find that information?
That would not be documented in the EHR.
In the laboratory section
In the progress notes section
In the immunizations section of the medical history
13
When SOAP noting is used for documentation, where would you find the diagnosis?
Assessment
Subjective
Objective
Plan
14
Clinical vocabularies can be accessed in the EHR by using which of the following?
Free text boxes
Radio buttons
All of the above
Drop-down menus
15
The provider's determination of what is wrong with the patient is found in which section of a SOAP note?
Subjective
Objective
Assessment
Plan
16
Which of the following areas of the EHR should a Patients progress notes be completed?
Clinical
Legal
Administrative
Financial
17
Which of the following can be used to assist with documenting patient care at the time that the care is provided?
None of these
Labtops
Cell Phones
Fax machines
18
HIPAA 5010
A professional orgnaization aimed to providing medical insurance education
the patient ledger stored in the medical office
a sum money that is owed to the physician
a format used to submit medical claims for reimburstment
19
When transmitting patient data for research purposes, which of the following should be done to protect the data?
Encryption
Deidentification
Abstract
Electronic data interchange
20
What is in the SOAP note?
Patient name
Insurance information
Observation of patient
NPP
21
When a patient has images done. Who does the scans.
Nurse Practioner
Radiologist
Nurse
Doctor
22
Codes for procedures and services such as evaluation and management services can be found in which manuals?
CPT
ICD
HIPAA
HCPCS
23
What is the first step in checking in a patient?
Check the patient in
Validare insurance
Place patient into a room
Verifying the idenity
24
A new patient must given a ___________ at the time of service to read and sign.
Notice of Privacy Practices
Account Number
Encounter Form
DNR
25
What data would be considered Legal?
Demographics
Consent Forms
Encounter Form
Medical Record Number
