question

During and/or after a visit with the provider

answer

Which of the following best describes when a treatment plan is generated?

question

a. What action steps will be taken to address the patient's problem(s) b. What service(s) were provided c. What procedure(s) were performed d. All of the above

answer

Which of the following questions should the treatment plan and treatment notes answer?

question

Electronic feed from a test instrument

answer

Which of the following is the most efficient way of adding the results of diagnostic test to the EHR?

question

Lab results

answer

Interoperability between LOINC terminology standard and an EHR assist in establishing what type of data exchange?

question

a. Patient b. Provider c. Patient's representative d. All of the above

answer

Which of the following individuals may be involved in the collaborative development of a patient's treatment plan?

question

Transmitting orders specified in the treatment plan to the appropriate health care practitioner

answer

To support the treatment plan, the EHR system must be capable of which of the following?

question

Demographic information

answer

Which of the following items is least likely to appear on a treatment plan?

question

To schedule a procedure with a health care provider

answer

A medical office would use a PMS to support which of the following functions?

question

A patient appointment

answer

A health care provider is most likely to find which of the following in her daily task list within an EHR system?

question

a. A referral letter b. A continuity of care record c. A continuity of care document d. All of the above

answer

A patient's primary care physician informs the patient that he needs to see a dermatologist. Which of the following information must "travel" from the primary care provider setting to the dermatology setting?

question

information about how to contact other patients with the same condition

answer

Per the ONC-ATCB Meaningful Use Criteria, at minimum the EHR system must be able to provide all of the following patient-specific education resources except:

question

a. Problem list b. Medication list c. Medication allergy list d. All of the above

answer

One feature of a certified EHR is that it can generate patient reminders for follow-up care. To accomplish this, the system would need to pull data elements from which of the following?

question

An EHR product must be flexible to enable a health care provider to define the specific data content it needs.

answer

Which of the following statements about an ambulatory EHR product is true?

question

Documentation of orders

answer

Which of the following components of an EHR product are the least customizable?

question

The "P" section

answer

Where within a SOAP-formatted treatment note in an EHR system would the physician document a patient's treatment?

question

Dr. Kimble creates a treatment plan as one of the items in the existing template.

answer

Dr. Kimble is documenting a patient exam at the point of care using a template. Which of the following best describes the process for developing a treatment plan for the patient?

question

The physician electronically signs the order.

answer

A physician has created an order for a patient within an EHR system. What happens as the next step in this process?

question

A physician

answer

Which of the following individuals within a medical office is least likely to act on an "open" order?

question

treatment note

answer

A physician will use a(n) ________ to document the outcomes of a therapy.

question

Use a template

answer

Which of the following is the best way to improve the completeness of a procedure note within an EHR system?

question

Via a scan of the results report and a manual update of the EHR order

answer

Dr. Pollen has ordered a PET scan for her patient which will occur at an imaging center in another location. How will the report detailing the results of this diagnostic test be captured within an EHR system?

question

a. It is intended to be transmitted directly between providers. b. It is a standard set of patient data. c. It facilitates direct communication of important patient information. d. All of the above

answer

Which of the following statements about the Continuity of Care Record (CCR) is correct?

question

voice mail

answer

Which of the following is not an example of electronic data interchange (EDI)?

question

order details

answer

When creating an order for a patient procedure within an EHR template, a health care provider needs to enter the _____.

question

Treatment plan

answer

The steps a health care provider intends to follow to address a patient's problem must be identified in which of the following?

question

The ability of the EHR to create discharge instructions

answer

When implemented by an EHR system, which of the following ONC-ATCB Meaningful Use Criteria most directly affects the patient?

question

digital images of the patient's x-rays

answer

Per the ONC-ATCB Meaningful Use Criteria, an EHR system must be able to transmit all of the following clinical patient information to another provider except ________.

question

a. AAAHC b. NCQA c. The Joint Commission d. All of the above

answer

Which of the following accreditation organizations requires that the treatment plans and therapeutic services provided to the patient be documented in the ambulatory patient record?

question

Eighth

answer

The Institute of Medicine report To Err Is Human: Building a Safer Health System stated that making medical errors ranks where as the leading cause of death among Americans?

question

a. NDC b. RxNorm c. Multum d. All of the above

answer

Which of the following is an example of a standard vocabulary for medications?

question

a. A possible unfavorable drug interaction b. A dosage outside the desirable range c.A free-text medication is entered d. All of the above

answer

Which of the following examples would cause a medication alert or reminder to be triggered within an EHR system?

question

A patient receives the wrong drug or an incorrect dose of a drug

answer

According to the IOM report, which of the following is the most likely type of error to occur within a health care setting?

question

Miscommunication of drug orders

answer

A pharmacy assistant has difficulty reading the handwriting on a prescription. This would be an example of which of the following common causes of medication errors?

question

a. A patient calls to request a refill b. A patient visits her primary care physician c. A patient contacts his doctor via a patient portal d. All of the above

answer

Which of the following would initiate the creation of a prescription within an EHR?

question

To find out the normal dose ranges for a specific drug

answer

Dr. Brown is ordering a prescription for Celebrix using an EHR system. As part of this process, Dr. Brown might use drug reference information for which of the following information?

question

Insurance identification

answer

A drug prescription order would not include which of the following?

question

Sample drugs

answer

In addition to identifying prescription drugs that have been prescribed for a patient, an EHR system must also be able to identify the dispensation of which of the following according to the CCHIT Ambulatory EHR Certification Criteria?

question

The EHR will not perform a formulary check against this uncoded drug.

answer

A physician uses free-text to enter a drug prescription within an EHR system. This will result in which of the following?

question

It helps keep track of the drugs a patient has taken over time, providing for longitudinal care.

answer

Which of the following would be considered a benefit of an EHR's ability to maintain an active medication list on each patient?

question

Patients

answer

In most cases, drugs prescribed to ambulatory care patients are administered by which of the following individuals?

question

RxNorm

answer

Which of the following provides standard names for both branded and generic medications?

question

990913-444-5

answer

Which of the following is not an example of the format for an NDC number?

question

Multum

answer

When a physician tries to order a medication for a patient, the EHR system issues an alert. Which of the following supplies the knowledge base that underlies this system function?

question

It checks to see if a drug is on a preferred drug list.

answer

What does a drug-formulary check within an EHR accomplish?

question

as needed

answer

What does the abbreviation PRN mean?

question

number of refills

answer

A health care provider uses an EHR system to order baby aspirin for a patient with heart disease. The physician needs to include all of the following information except the ______ to complete this order within the system.

question

Before the provider signs the processing order

answer

At which point in the drug ordering process does the EHR system compare drug order details against system rules?

question

a. Patient demographic and clinical information b. Drug reference information c. Decision rules built into the system d. All of the above

answer

In order for an EHR system to generate a drug alert, it requires which of the following data?

question

The provider may still prescribe the drug as long as he or she supplies a rationale.

answer

An EHR system has generated a medication alert. This leaves the health care provider with which of the following options?

question

The patient has finished his first course of the blood thinner Coumadin (warfarin).

answer

Which of the following situations would most likely trigger an EHR system to generate a follow-up testing reminder?

question

Reminders

answer

Which of the following features of an EHR system is most likely to improve patient drug compliance?

question

Patient's age

answer

A health care provider who is ordering a medication for a patient requires which of the following patient-specific data in order to select the correct medication?

question

Lack of appropriate drug labeling

answer

A certified EHR system would be least likely to solve which of the following causes of medication errors?

question

It must be updated frequently.

answer

Which of the following statements about drug reference information is correct?

question

sentence

answer

Another term for order format and details is an order _____.

question

a. Pick lists guide the selection of the specific medication and appropriate dosing. b. The practitioner can click on drug reference information. c. Electronic communications prevents misreading of handwritten orders. d. All of the above

answer

Which of the following are ways in which the EHR can address some of the root causes of medical errors?

question

a. HCPCS b. ICD-9-CM c. ICD-10-PCS d. All of the above

answer

Which of following has HIPAA mandated as code sets to be used in ambulatory care interactions?

question

Twice a year

answer

How often are ICD-9-CM codes updated?

question

Natural language processing

answer

Which of the following is a method used by CAC (computer-assisted coding) for electronically translating documentation in the patient record into a code?

question

CPT is a classification system.

answer

Which of the following statements is false regarding procedural coding?

question

a. Direct keyboard entry of text b. Structured data entry utilizing templates c. Dictation with subsequent transcription of voice to text d. All of the above

answer

According to the CCHIT Functional Criteria, which of the following means can be used to document encounters?

question

Before the patient visit

answer

When does the coding and billing workflow begin?

question

WHO

answer

The International Classification of Diseases is coordinated by which of the following organizations?

question

DSM

answer

HIPAA does not mandate the use of which of the following code sets?

question

Evidence in the patient's record

answer

Which of the following is used to support the selection of a particular diagnostic or procedural code once it has been assigned?

question

After the diagnosis is recorded

answer

At what point in the coding and billing workflow are codes assigned?

question

The health care practice

answer

Who is the recipient of an explanation of benefits (EOB)?

question

American Medical Association (AMA)

answer

Which of the following organizations is not a member of the Cooperating Parties?

question

Volume 3

answer

Which volume of ICD-9-CM codes are not typically used by medical office practices?

question

Mapping

answer

The process of linking the content from one coding terminology or classification to another is known by which of the following terms?

question

HCPCS Level II codes

answer

Which of the following procedural codes may be used to indicate the provision of durable medical equipment to a patient?

question

A federal information system vocabulary standard

answer

Which of the following best describes SNOMED-CT?

question

Upcoding

answer

The practice of documenting services that were not actually provided to a patient is known as which of the following terms?

question

Cost to implement

answer

Which of the following would not be considered an advantage of a CAC coding system?

question

Scrubbing bills

answer

Which of the following jobs may be performed by a claims clearinghouse?

question

A report that includes more than one patient with diabetes

answer

A diabetes roster would be an example of which of the following?

question

Natural language processing

answer

Which of the following is an example of a method used to identify terms for CAC?

question

They specify the complexity and level of an office visit.

answer

What is the purpose of E/M codes?

question

Volume 1 of ICD-9-CM

answer

The Tabular List refers to which of the following?

question

It is a listing of terms.

answer

CPT is a nomenclature. What does this mean?

question

a. SNOMED-CT b. ICD codes c. HCPCS codes d. All of the above

answer

In order to fulfill most payment and reporting requirements, an EHR system would need which of the following?

question

AHA AHIMA CMS NCHS

answer

List the four groups responsible for providing recommendations for updates of ICD in the United States.

question

Phase II

answer

A clinical trial is testing the effectiveness of a new drug on several hundred healthy individuals. What clinical trial phase does that statement describe?

question

Phase IV

answer

Approval of a new product has been received from the FDA, and thousands of individuals are involved. What clinical trial phase does that statement describe?

question

AAAHC

answer

Which of the following has standards requiring that documentation relating to research monitors be separate from standard visit documentation?

question

FDA

answer

In order to reach the market, a new drug must receive the approval of which of the following agencies?

question

To define the plan for performing testing on humans

answer

What is the purpose of a protocol that is used in a clinical study?

question

To select an appropriate principal investigator

answer

Which of the following would not be considered a function of the Institutional Review Board?

question

Phase III

answer

At what step in a clinical trial would a placebo be introduced to volunteer subjects?

question

Treatment

answer

In general, which is the most common type of clinical trial?

question

Prevention

answer

A group of volunteers are being selected for a study that tests the benefits of regular exercise on cardiovascular health. It is most likely that these volunteers are part of which type of study?

question

Location depends on the study

answer

Where do clinical trials typically occur?

question

To ensure that older volunteers were included in studies

answer

Why did Medicare begin approving certain treatment studies in 2000?

question

Daily blood work to monitor drug levels

answer

It is unlikely that Medicare would pay for which of the following services that has been received by a Medicare patient who is also part of a clinical trial?

question

a. It must include the trial name and its sponsor. b. It must include a copy of the patient's signed consent to participate in the study. c. It must clearly identify research-related treatment as separate from regular care. d. All of the above

answer

A patient indicates that she is participating in a clinical study. What are the requirements of the health provider's EHR in regards to this patient?

question

When the information includes patient identifiers

answer

Per HIPAA, when does shared patient information require a patient release of authorization?

question

To remove the patient from the study

answer

Following assessment, a physician believes a patient's nausea may be a result of the experimental drug he is taking. Which of the following would not be considered the physician's obligation?

question

Third-party payers are more likely to cover treatment studies than any other type of study.

answer

Which of the following statements regarding third-party reimbursement for medical care provided as part of research studies is correct?

question

payment for participation

answer

Per the Joint Commission, a patient who is considering participation in a research study must receive all of the following except a(n) ____.

question

a. Cancer data related to a region b. Information on newborn birth defects c. Immunization data d. All of the above

answer

A registry would be likely to include which of the following?

question

The patient has viral meningitis

answer

The Joint Commission section of the Rights and Responsibilities of the Individual states indicates that identifiable information about a patient may be disclosed or reported without the patient's consent in which of the following cases?

question

A lawyer

answer

A research team is least likely to include which of the following professionals?

question

Checking a protocol for HIPAA compliance

answer

A Privacy Board is charged with which of the following?

question

quality-of-life

answer

A patient with end-stage renal failure would be most likely participate in a _______ trial.

question

The volunteer's primary physician must approve their patient's participation in the study.

answer

Meeting which of the following criteria is not necessary before a volunteer is permitted to participate in a clinical trial?

question

A service typically provided absent a clinical trial

answer

Which of the following examples of patient care services will Medicare pay for during a Medicare Qualifying Trial?

question

Treatment

answer

As a study participant, Jared is taking a new combination of drugs for his glaucoma. Based on this information, it is most likely that Jared is a participant in which type of trial?

question

case report form

answer

A ______ is a summary of research findings for a particular individual so that data can be consistently gathered across participants and statistical evaluation performed.

question

A disorder that poses a risk to the health of the general public

answer

Which of the following best describes a reportable event?

question

a. Paper file b. Web-based private account c. Smart card d. All of the above

answer

In what formats might a personal health record be maintained by the patient?

question

It is a tool for communication between authorized health care provides from different settings.

answer

Which of the following statements is accurate related to a continuity of care record (CCR)?

question

Health care providers

answer

According to the National Committee on Vital and Health Statistics one benefit of a PHR is improved medication compliance. This is listed as a primary benefit to which of the following groups?

question

The provision of convenient service

answer

An employer might experience which of the following benefits from a PHR?

question

Verify that state or federal laws do not prohibit sharing of the requested information

answer

An elderly patient contacts her health care provider to request information she would like to add to her PHR. In response, what does the practice do first to fulfill this patient's request?

question

AHIMA

answer

Which of the following was the first organization to define what content should be included in a PHR?

question

Insurance provider type

answer

The personal information section of a typical PHR would not include which of the following?

question

Comprehensive

answer

Select the best adjective to describe a personal health record (PHR).

question

The patient

answer

Who is primarily responsible for the content contained in a PHR?

question

a. Contact AHIMA to find out what they recommend b. Review information provided by Medicare or others on choosing a PHR c. Contact his health care plan to find out if they are developing a PHR. d. All of the above

answer

Mr. Davidson decides he would like to create a personal health record because he takes many different medications. If Mr. Davidson wants to make it easy to share his PHR with his different doctors, he should do which of the following?

question

Note that the information was shared in the patient's record

answer

According to HIPAA, a cardiologist who needs to share the confidential results of a test with a patient's primary care provider must do which of the following?

question

Sharing patient information about a communicable disease

answer

Per HIPAA, which of the following is an example of a specialized release of information?

question

Physical Examination

answer

Which of the following is not an example of an AHIMA-identified PHR data category?

question

Health record output

answer

Mrs. Jennings contacts the pediatrician to request a copy of her daughter's immunization records. This would be an example of which of the following CCHIT Ambulatory EHR Certification Functional Criteria category?

question

Organized data elements

answer

A physical therapist who electronically shares patient information via a secure computer network to the patient's primary care provider would use which of the following formats?

question

No guidelines currently exist

answer

At minimum, a health care provider is required to share which of the following elements from the patient record with another practitioner?

question

Health care providers

answer

The continuity of care record facilitates communication among which of the following groups?

question

a. To enhance patient safety b. To reduce costs c. To reduce medical errors d. All of the above

answer

Which of the following is the purpose of a CCR according to the ASTM standard specifications?

question

a. Before the patient visit b. During the point of care c. After the patient's visit d. All of the above

answer

At what point would a CCR for an individual patient be produced?

question

Within the CCR header

answer

Within which section of a CCR does the reason for its generation appear?

question

It is generated on an as-needed basis.

answer

A CCR differs from a PHR in which of the following ways?

question

Individuals associated with the CCR data

answer

The body section of the CCR would include all of the following except:

question

Social history

answer

A patient's occupation belongs in which of the following categories?

question

Correct patient identification

answer

Which of the following is the most important aspect of information sharing using a CCR?

question

Include it as part of the legal definition of the practice medical record

answer

In the future, it may be necessary to do which of the following in relation to data from the CCR?

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