EHR – Ch#5 – Flashcards
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Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low grade fever for the past four days. This is known as _______________. a) subjective information b) objective information c) an assessment d) a diagnosis
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a) subjective information Information which is given by the patient is subjective.
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Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Philips, by typing the sentences: "The patient is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He voices no other complaints." This is an example of _________________ data. a) structured b) unstructured c) subjective d) objective
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b) unstructured Since the nurse is typing this information in paragraph form and without the use of drop down menus, this is unstructured data.
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In a hospital setting, the care provider takes the patient's history, details the reason the patient is being admitted and performs a physical exam. The report of this information is known as the: a) initial progress note b) discharge summary c) history and physical d) SOAP note
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c) history and physical In the hospital, care providers compile patient history, reason for admission, and results of a physical exam into a report commonly known as the history and physical (H&P).
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The results of a patient's rapid strep test would be found in what area of a SOAP note? a) Subjective b) Objective c) Assessment d) Plan
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b) Objective Measurable results, as in the case of a rapid strep test (positive or negative) are objective data.
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The SOAP documentation format is most commonly used in which healthcare setting? a) hospital inpatient b) physician's office c) hospital emergency department d) outpatient diagnostic department
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b) physician's office Documentation in a physician's office is more precise and is related to what is wrong with that patient at the time of the visit. Therefore, SOAP note format is an efficient means to collecting the required information.
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Dr. Schultz has just examined Natalia Shrier who had come to see him because she has been having increasing problems with gastroesophageal reflux. Dr. Schultz has instructed Natalia to avoid hot, spicy foods, to avoid eating within three hours of going to bed, to raise the head of her bed, and has given her an order to have an Upper GI x-ray. Dr. Schultz's instructions are part of which element in a SOAP note? a) Subjective b) Objective c) Assessment d) Plan
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d) Plan The treatment instructions given and the order for an x-ray are part of the physician's plan of care, otherwise known as the Plan in a SOAP note.
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In a hospital setting, what document is the equivalent of the assessment and plan that is collected as part of a SOAP note in an outpatient record? a) History and Physical b) Discharge Summary c) Progress note d) Procedure note
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b) Discharge Summary For a hospital inpatient, the care provider must summarize the patient's hospital course; the final diagnosis and plan of care are part of the discharge summary.
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Alison Holt just received a copy of her Clinical Visit Summary from the visit to her primary care provider earlier in the day. She is reading that her symptoms were present for the past four days, and that she did not get any relief from Motrin. To which section of the SOAP note does this information pertain? a) Subjective b) Objective c) Assessment d) Plan
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a) Subjective Since information such as the duration of symptoms and modifying factors, such as taking a medication, come from the patient, this is considered subjective data.
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During the history, Kevin Goodell notes that the pain in his right hip is more of a dull pain than an ache. This is considered what part of the history of present illness (HPI)? a) location b) quality c) severity d) modifying factor
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b) quality A description of the type of pain is known as the quality element of the HPI.
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A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI). a) associated signs and symptoms b) modifying factors c) severity d) location
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c) severity The fact that her pain is an 8 on a scale of 1 to 10 refers to the severity of the pain.
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A patient with knee pain has been using pain patches to alleviate the pain; she has been using the kind that are left on the area for several hours. Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI). a) location b) timing c) severity d) modifying factors
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d) modifying factors She tried to manage the pain herself with the pain patches, but they were only partially successful, therefore this would be a modifying factor.
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The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient's visit. a) care plan b) charges c) diagnosis d) assessment
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b) charges
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Neil Rabinski was asked by the care provider if he has had any difficulty breathing, shortness of breath, or noticeable wheezing. This is part of the review of systems for the __________________ system. a) gastrointestinal b) head/eyes/ears/nose/throat c) respiratory d) cardiovascular
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c) respiratory
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The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)? a) musculoskeletal b) gastrointestinal c) neurologic d) constitutional
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d) constitutional Vital signs, general health, and weight changes are all part of the constitutional findings in the ROS.
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Which of the following professionals would not perform a physical examination (PE)? a) medical assistant b) physician's assistant c) nurse midwife d) nurse practitioner
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a) medical assistant Since only care providers perform PEs, a medical assistant would not be qualified to do so.
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Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _____________ are assistants who may enter the information. a) transcriptionists b) scribes c) dictators d) nurses
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b) scribes Though it is possible that a nurse may be the assistant who does so, scribes are the professionals who are hired specifically to perform that task, and it is therefore the more accurate answer than nurse.
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The healthcare professional who types reports for care providers is known as a/an ______________. a) dictator b) transcriptionist c) transcriber d) scribe
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b) transcriptionist A transcriptionist types reports dictated by care providers.
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Which of the following is an advantage of dictation and transcription? a) most physicians prefer it to any other method of documentation b) very inexpensive as compared to written notes c) saves on paper and supplies as compared to speech recognition d) allows for greater accuracy than written notes
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d) allows for greater accuracy than written notes
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Which of the following is a benefit of voice recognition? a) lower cost to implement b) from the beginning it is less time consuming for the care provider c) documents are made part of the patient's record in a timelier manner d) one hundred percent accuracy is attainable
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c) documents are made part of the patient's record in a timelier manner
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One of the reasons ePrescribing is being used by a greater number of physicians' practices is that it:
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is a requirement of the HITECH Meaningful Use regulations. In order for physicians to receive incentive money from the HITECH Act, they must show that the electronic health record is being used in a meaningful way. Electronically prescribing medications is one way that improves accuracy, monitors for drug interactions, and improves efficiency.
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Of the following, which is not a benefit of ePrescribing? a) the patient's demographic and insurance information is sent to the pharmacy from the office b) there is less chance of medication errors being made c) it is less expensive for the patient d) care providers and pharmacists are alerted to possible food/drug or drug/drug interactions
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c) it is less expensive for the patient There is no effect, positive or negative, on the cost to the patient when ePrescribing is used
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A computerized system which allows physicians to request lab, radiology, or pharmacy services for their patients is known as: a) electronic health records b) computerized physician order entry c) electronic prescribing d) orders requisition
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b) computerized physician order entry
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In order for any test, procedure, or medication to be administered to a patient, there must be a: a) SOAP note b) History and Physical exam c) care provider's order d) consent from the patient
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c) care provider's order
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In order for Dr. Reynolds to send a CPOE from her office computer system to the computer system at the local hospital, a/an ____________________ must exist between the two computer systems. a) cable b) interface c) internet d) firewall
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b) interface The two computer systems must be able to "talk to each other" or communicate in order for the sent message to be read by the receiving computer. This is known as an interface.
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Which of the following is a benefit of CPOE? a) the results of a test are instantly received b) the patient receives his/her test results at the same time as the provider c) clinical decision support is possible through CPOE d) using CPOE is less costly for the patient
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c) clinical decision support is possible through CPOE Though the order is sent instantly, once the provider hits send, the results are not instantaneous; the patient does not receive the results until the office notifies him/her of the results; use of CPOE does not affect the patient monetarily in any way. CPOE does, however, flag for any drug-drug interactions, dosing inconsistencies, etc., when used for prescribing.
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If a computerized physician's order is sent to the local hospital for a blood test, and the physician's office has already been notified of the test findings, this order is: a) pending b) ordered c) returned d) scheduled
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c) returned If an order has been placed (ordered) and the results have been sent back to the ordering physician, this is known as being returned.
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Emily Haver is being seen by Dr. Clark today for her annual physical exam. She has been a patient of his for many years. She is currently being treated for hypertension and type 2 diabetes mellitus. In the late 1990's she was treated on several occasions for poison ivy. She has been treated since 2003 with Zoloft for mild depression. Of the following, which will not appear on Emily Haver's problem list? a) hypertension b) diabetes c) poison ivy d) depression
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c) poison ivy Since poison ivy is an acute condition, and from the documentation given she is no longer being treated nor does it affect her current care, the problem is no longer active nor current.
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Meaningful Use guidelines require the keeping of an up-to-date: a) dictation system b) chart note c) problem list d) past medical history
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c) problem list A current problem list must be maintained to meet Meaningful Use requirements.
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Of the following, which is not an element of the history of present illness (HPI)? a) duration b) severity c) quantity d) quality
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c) quantity A physical exam includes objective findings of the care provider while the HPI includes the signs or symptoms that a patient communicates to the provider, such as the duration, severity, and quality of pain.
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In PrimeSUITE, as with many other electronic health record systems, healthcare professionals and healthcare providers can access a patient's health record to determine the status of orders for testing or prescriptions. This is known as: a) computerized physician order entry b) orders tracking c) discharge planning d) orders status
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b) orders tracking Orders tracking allows the provider and the healthcare professionals to know if a patient has given a specimen, whether the results are pending, or the order has been resulted (results sent to ordering provider).
