Subjective data is the ___.

patient's own words of chief complaint

How do you make sure the process of requesting reimbursement is accurate ?

confirming diagnosis and procedure codes support the documentation

How does templates in an EHR help the efficiency of office staff when documenting?

increases completeness and accuracy

Administrative safeguards are included in __.

biannual security awareness training

A benefit of using the CPOE feature is__?

helps prevents the duplication of orders

When a change has been made to previous process, how is the change upheld in the office?

Automatic alerts regarding change

Patient payments are posted at what stage in the patient flow?

during check in at point of service

Ms. Add has been off work for several days. She believes someone has accessed her computer. What is the next step?

Perform an Internal access review

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EHR Competency Study Guide

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Answers

1
A Release of Information must be signed before a patient can have a noncovered procedure.
True
False
2
Subjective data is the ___.
patient's own words of chief complaint
nurse's documentation of vitals
physicians documentation of visit
EHR specialists billing documentation
3
In what section of the EHR would a patient's smoking and drinking status be documented?
demographic data
medical history
HIPAA form
physical examination
4
Third party payers are whom?
physicians
laboratories
insurance carriers
patients
5
Grouping the ____, improves the office flow for better efficiency.
types of appointments
amount of copays
type of insurance
age of patients
6
How do you make sure the process of requesting reimbursement is accurate ?
confirming the diagnosis is covered under the patients insurance
confirming the physician, patient, and date of service
confirming the patients demographic
confirming diagnosis and procedure codes support the documentation
7
Outside lab resources can be mapped by __.
CMS
HIPAA
MIPS
LOINC
8
Evaluation and Management codes are found in the ICD-10-CM book.
False
True
9
Diagnosis based lists help who when charting?
janitor
receptionists
physician
patient
10
A major roadblock for implementing an EHR is cost.
False
True
11
Who is responsible for verifying insurance?
billing staff
lab tech
physician
nurse
12
Portions of medical records can be provided to county health departments and other government agencies when it is?
anonymous and confidential
consent from patient
HIPAA form signed
Release of information is signed
13
Reporting of health outbreaks to the public is done by what means?
syndromic surveillance
lab reports
physician registry
data registry
14
How does templates in an EHR help the efficiency of office staff when documenting?
increases completeness and accuracy
increases timely filing
increases effectiveness and accuracy
increases requirements for CMS
15
Administrative safeguards are included in __.
OIG Compliance plan
Transcripted data
Clearinghouse guidelines
biannual security awareness training
16
Decision support software can be used to help determine ___ of drugs.
procedural codes
billing diagnosis
side effects
therapeutic equivalence
17
All transmitted data must be__ to meet security standards.
readable
encrypted
all alpha numeric
all numeric
18
A benefit of using the CPOE feature is__?
calculates E/M level
verifies patient identity
helps prevents the duplication of orders
adds the facility cost of orders
19
Cloned progress notes lead to __.
increased work flow
coding accuracies
out dated documentation
higher reimbursement
20
When a change has been made to previous process, how is the change upheld in the office?
Automatic alerts regarding change
Automatic alerts to the receptionists
Automatic alerts to the provider
Automatic alerts to the billing department
21
Verification of insurance should be completed prior to ___?
verifying appointment time
verifying physician being seen
taking point of care payments
taking money on balance owed
22
Electronically verifying insurance information the night before can be the role of the __.
nurse
EHR Specialists
physician
insurance clerk
23
Maintaining the scope of practice compliance helps to maintain the ____ of EHR data.
charting
templates
efficiency
integrity
24
Point-of-Care documentation benefits the EHR by helping with __.
progress notes
e-scribing
templates
completeness and accuracy
25
Patient payments are posted at what stage in the patient flow?
during check out
after the patient leaves the office
during the triage
during check in at point of service
26
The encounter form includes a comprehensive and up to date list of a patient's medical conditions.
False
True
27
The use of EHR systems has made the record process__.
difficult and harder to access
improved and streamlined
scattered and time consuming
complete and accurate
28
Protocols are used to determine __ per medical conditions.
referring surgeons
payments
types of therapies/treatments
medications
29
Information for EHR systems is stored on USB drives.
False
True
30
Who is responsible for upholding the minimum number of years medical records should be retained.
HIPAA
CMS
OCR
OIG
31
HIPAA sets standards for who can access protected health information.
False
True
32
Ms. Add has been off work for several days. She believes someone has accessed her computer. What is the next step?
Perform an Internal access review
Nothing
Change her password
Perform a camera search
33
What must be created when implementing an EHR system?
Office
financial account
computer system
committee
34
CPOE can be used to help with __.
All of the above
duplicate prescriptions for pharmacies
radiology requests
laboratory requests
35
Who requires information to backed up in a secure location?
DHHS
CMS
HIPAA
OIC
36
Which is a "DO NOT USE" abbreviation per Joint Commission?
all of these
MSO4
QD
IU
37
ICD-10-CM, CPT and HCPCS Level II codes are examples of what type of data?
templates
objective
subjective
structured
38
Any clinical data entered wrong into the EHR is corrected by what means?
strike through with initial and date
deletion of DOS
deletion of mistake
addendum
39
Two ways to look for an established patient in the EHR system?
patient's mother, guarantor
chief complaint, PFSH
zip code, state of residence
social security number, DOB
40
Which code set is used for inpatient procedures and services?
CPT
HCPCS Level II
ICD-10-CM
ICD-10-PCS
41
Uncompleted encounter forms cannot be used for billing because they lack ___ to be complete.
chief complaint
insurance verification
diagnosis and procedure codes
review of systems
42
What type of report can see the revenue from CPT codes?
Accounts Receivable
Billing Department
Accounts Payable
Pending Transactions
43
What can be reviewed to see if patients PHI has been compromised?
Accounts payable
Aging report
Systems activity review
Demographic data
44
The EHRS will use a ____ to cross check data on specific treatment options for patients with a certain diagnosis.
database of medical links
data registry
data warehouse
data medical set
45
You must always____ first when checking in a patient.
verify date of birth
verify contact information
collect insurance information
verify appointment time
46
You are allowed to leave a patients information on a computer screen without having any security issues.
False
True
47
Day sheets are used at the beginning of the day.
False
True
48
Dr. Smith needs to access Dr. Jones records for David Williams, what type of care is this?
Transfer of care
Continuity of Care
all of the these
Referral Care
49
Appointment time can be used as a patient identifier.
True
False
50
What section of the EHR can an EHR specialists document?
ALL of the answers
progress note
third party payers
chief complaint
51
Where is an ongoing measurement entered into the EHR?
flow sheet
intake form
encounter form
ROS
52
What is the first step in preparing to bill out a claim or operative report?
none of these
making sure the diagnosis and procedure support the documentation
making sure the physician is correct
making sure the highest level is coded regardless of procedure
53
Joan logins to an unattended workspace using her credentials. This is an example of what type of regulatory provision?
Internal Audit Access control
HIPAA Security Rule
CMS Rule
None
54
How is David Smith's MRI added to his chart correctly and not into David Schmidt's .
downloading
export
import
cataloging
55
What type of EHR feature is a requirement by CMS and is used if a 2 month old is needing his/her vaccinations?
Clinical Quality Measures
E-scribing
Past medical History
Utilization Review
56
To be considered interoperable, systems must share____.
unified language system
all of the above
databases
networks
57
The provider documented a diagnosis of Hypertension during an office visit. This is _____documentation.
nurse note
consent
progress note
real-time and point of care
58
The process of selecting data from the clinical and administrative decision making is the process of __.
abstracting the appointment schedule
abstracting a medical record
abstracting the physicians schedule
abstracting the laboratory schedule
59
Integrity deals with what type of data?
modified data and encrypted
misinterpreted and lost data
encrypted and unreadable until reaches destination
archived and shredded data
60
Templates can be customized to work with each provider's workflow.
False
True
61
What section of the medical record is the chief complaint listed?
plan
assessment
objective
subjective
62
Alcohol usage is documented in the social history section of the EHR record.
False
True
63
What data is entered prior to a visit in a patient-entered data collection system?
current radiology procedure results
recent surgeries and reason for visit
recent refills on prescriptions obtained
date of last office visit
64
Jacob Lively presents to his PCP today and is complaining of a sore throat, where is this documented?
Admission sheet
Day sheet
Encounter form
Intake form
65
Where can you find out how may refills was on a prescription?
CDSS
MAR
CMS
CPOE
66
---- is used for catastrophic events.
power source
contingency plan
extra equipment
Back up data system/process
67
The physical examination includes___.
Diagnosis
subjective data
T-P-R-BP
Plan of care
68
CPOE...
Computerized Program Order Entity
Computerized Physician Outpatient Entry
Computerized Program Order Entry
Computerized Physician Order Entry
69
Corrections to clinical data can only be done by creating a (an)__.
new progress note
new patient visit
addendum
superbill
70
When a limited number of workstations are available, a mobile device can be used to access the EHR for data entry.
False
True
71
The identity of the patient, along with the insurance and emergency contact is documented here:
face sheet
day sheet
encounter form
superbill
72
Where can Health Care literature can be accessed within the EHR .
Demographic
Progress notes
CDC
medical reference links
73
How is a diabetic's insulin pump information transferred into their medical chart without having to go to the office?
all of the above
fax
email
telemetry
74
Aging reports can be generated to determine monies owed by guarantor(s).
False
True
75
Examples of de-identified information is:
DOB
zip code
All of the above
Patients name
76
The CMA wants to know what the next patient is being seen for. Where and how will the CMA know that information?
patient past appointments and current appointment time
face sheet and intake form
date of birth and insurance information
scheduling tool and chief complaint
77
During the implementation of a new EHR system, duplication of orders are expected when _____.
going from one facility to another
going from paper to electronic records
going from one doctor to another
going from receptionists to nurse
78
What would help in ordering multiple services or tests at one time on a template?
CPT codes, ICD-10-CM codes
checkboxes
specimen types
empty lines
79
A Risk management process is performed first to determine threats to the confidentiality and integrity of PHI.
False
True
80
An example of subjective data is __?
BP 110/72, wt. 150 LBS. R: 60
Pt.s address
past operative note in chart
sore throat, cough
81
Why would an EHRS be requested to generate a bi-monthly financial report for each physician in a group practice?
determine number of patients seen
none of the above
determine monthly revenue
determine number of no show patients
82
Syntactic interoperability provides the most efficient communication between systems.
False
True
83
CMS uses what to determine quality improvement?
DRG's
CPT
MIPS
ICD-10
84
Formulary compliance is not a feature of e-scribing software.
True
False
85
What organization sets the guidelines for research?
Healthlevel 7
CMS
OIG
OCR
86
What is the best way to reduce or even prevent discrepancies in data?
by manual entry of data
use of scanned documents
use of digital images
none of the above
87
BY utilizing e-scribing and eliminating written prescriptions, the office can ___.
streamline workflow
decrease patient portal activity
increase visit times
increase prescription adherence
88
Professional charge reports are generated by __?
CPT Codes
Functional Modifiers
POS Codes
ICD-10-CM Codes
89
By ____, inaccuracies in coding are almost preventable ?
performing mandatory updates
performing peer to peer reviews
performing routine internal audits
set alerts for coding changes
90
Real-time data is considered____ data.
assessment
demographic
objective
subjective
91
EHR hardware includes
glucose meter
storage device
BP machine-manual
urinalysis machine
92
After a heavy patient load for the morning, what part of the PMS system is used to check patient load for the afternoon?
Accounts receivable
Patient list
E-scribing
Scheduling tool
93
MIPS and DRG's are used by whom?
Cigna
Blue Cross
Medicare
Medicaid
94
Patients must be notified within how many days of a breach of security?
90 days
10 days
45 days
60 days
95
How is billing information exchanged from one entity to another?
Electronic data exchange
Electronic Data Interchange
Health information exchange
Internet
96
Medicare patient's must sign a ___ for noncovered services, procedures. etc.
ABN
HIPAA forms
Release of Informaton
Notice of Privacy Practices
97
An example of real time documentation is when a physician documents in the problem list during an encounter.
True
False
98
If an office has an interruption in their daily business, what must be in place?
back up data system
plan for testing and revision procedures/ contingency plan
back up power source
Extra storage devices
99
What type of review is performed before billing can be completed?.
internal
retrospective
prospective
external
100
Ms. Scott is diagnosed with Hypertension, where can the EHRS find educational material about the new diagnosis?
diagnosis list
chief complaint
clinical decision support
patient portal

EHR Competency Study Guide Flashcards | StudBud