Integrated Electronic Health Records Chapters 1 & 2
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Selecting software that communicates with other software prevents
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duplication of entries and also cuts down on errors, since the data is only entered one time.
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Of the following, which is not an application of an EHR system? A. capture of past social history B. capture of medication allergies C. capture of insurance policy number D. ability to send a prescription electronically
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capture of insurance policy number
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Dr. Evans' office has computerized the following functions: appointment scheduling, charge capture, collections, and reporting. These are all found in which type of software
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practice management
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Christine Simmons arrived for her appointment with Dr. Shumaker 20 minutes ago. The healthcare professional has just left the room after taking Christine's vital signs and medical history. What will be the next step in Christine's flow through the overall process?
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care provider
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Jesse Lopez is a healthcare professional at Green Springs Internal Medicine. He has just finished submitting claims to Blue Shield for patients seen yesterday. Jesse was performing what type of function?
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administrative
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You are a registrar in the admitting office of a hospital; a patient presents to register for an outpatient laboratory test. What will you first access to determine if that patient has ever been seen at that hospital before, or whether you must register him for the first time?
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master patient (person) index
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Physicians' practices sometimes use a service to check for errors on claim forms prior to submitting a claim to the insurance company. The service that processes insurance claims is a
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clearinghouse
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Roberta is a healthcare professional at Dr. Ingram's office. She has a patient on the phone who wants to make an appointment with Dr. Ingram. What will Roberta take into consideration when looking for an open appointment time?
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the reason for the patient's visit
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Pieces of data which identify a patient and include such items as name, address, and date of birth are considered what types of data?
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demographic
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\"Which of the following is not a type of medical insurance? A. Medicare B. Tricare C. Self-pay from patient D. Workers' Compensation
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Self-pay from patient
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The documentation of a patient's office visit is often referred to as a/an:
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Progress note
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Though the costs of implementation will be high, which record-keeping costs will be less as a result of implementing an electronic health record?
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cost of folders and clips to file each record
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Of the following, which contributes to the high cost of electronic health records for the software service provider?
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research and development costs
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Which of the following statements accurately describes duplicate patient registration entries in an electronic health record system?
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duplicate patient registrations can occur if the patient's name was misspelled or the patient was previously registered under a different name
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Which of the following EHR applications may be more beneficial and efficient for the patient?
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ePrescribing
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What must a care provider do before he/she will see the benefits of an EHR in relation to time spent documenting each patient's visit?
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devote time to learning the new system
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Research has shown what, in relation to the use of an EHR?
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there has been decrease in medical errors through use of EHR software
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Which of the following is not clinical information?
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age
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A care provider is dictating a progress note into speech recognition while the patient is being seen. This dictation is occurring:
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at the point of care
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During the history of present illness, the healthcare professional asks Ron Albertson for his preferred pharmacy. The healthcare professional then enters the information into PrimeSUITE. After the care provider has examined and diagnosed Mr. Albertson, he prescribes Amoxicillin and electronically sends the prescription to Mr. Albertson's chosen pharmacy without having to enter any additional information into the ePrescribe module. This is an example of:
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interoperability
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The first step of the information chain in an electronic system is:
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Patient makes the appointment
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Posting patient charges occurs during which step(s) of the process in an office setting?
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check-out desk
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You are a healthcare professional at Greensburg Medical Center and you have just shown a patient, Mrs. Clark, to the check-out desk, where the billing coordinator had just taken the encounter form (superbill) for the visit. Dr. Daniels came to the window and stated that Mrs. Clark left the exam room before receiving her flu shot. What will occur in this case?
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Mrs. Clark will be taken back to the exam room, will be given the shot by the healthcare professional, who will document it in Mrs. Clark's record, and will update the encounter form to reflect the charges for the flu shot, at which point Mrs. Clark will return to the check-out desk
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Of the following, which does not need to be sent to an insurance company on the CMS-1500 claim form?
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History of present illness
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The steps listed below are carried out by which staff during an office visit? Patient Arrives for visit > Update Patient Information > Check In and Collect Co-pay > Start Patient Tracking
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Registration/Front-desk
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Joyce Burke is a healthcare professional working at Greenway Medical. She is responsible for compiling insurance claims and checking them for completion. Which area of the office does Joyce work in?
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Business Office
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Memorial Hospital is in the process of researching a new facility-wide electronic health record system. The ___________________ would be responsible for assessing the budgeting process, funding, and for monitoring the monetary aspects of the project.
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chief financial officer
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Roberta has an associate degree and holds RMA certification. She mainly performs administrative duties such as appointment scheduling, registering patients, and maintenance of health records in a large physician's practice. She occasionally performs clinical duties as well, as needed. Roberta is a/an:
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medical assistant
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In a hospital setting, the management and much of the staff of the department responsible for entering, maintaining, and retrieving data from health records, are often certified through and members of which professional organization?
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American Health Information Management Association (AHIMA)
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Which of the following requires completion of a competency exam, but does not result in certification?
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Practice Workflow & Information Management Redesign Specialist
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The health information manager and the ___________________ work closely to ensure a fully operational, secure electronic health record that meets the needs of all users within the facility?
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Information Technology Manager/Officer
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Robert Fitzsimmons is an administrator with the local hospital. His responsibilities include the maintenance and security of all of the automated systems that affect individual departments as well as the electronic health record. Mr. Fitzsimmons is a/an:
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health systems administrator
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The staff of the ___________________ will need to enter, maintain, and retrieve data from electronic health records within a hospital setting.
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health information department
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Until recent years, Registered Health Information Technicians, Registered Health Information Administrators, and Certified Health Data Analysts typically worked in which type of facility?
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hospitals
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Which of the following is not a professional organization related to the fields of health information, medical assisting, or allied health?
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American Hospital Association
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Philip is a medical assistant who has been working for a medical practice with two physicians and one physician's assistant for three years. He recently applied for a supervisory position within the office, but was overlooked for the position. He is anxious to take his knowledge and experience to the next level, but never took a certifying exam, and to this point has not taken advantage of continuing education opportunities. What is the best strategy for Philip to strengthen his chances of promotion in the future?
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begin studying for one of the medical assisting certifying exam and schedule a date to take it
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A ______________________ professional would most likely hold one of the following positions: cancer registrar, privacy officer, software analyst, compliance officer.
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Registered Health Information Administrator (RHIA)
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In a physician's practice, ________________ may be the title of the person who is responsible for the overall administrative management of the practice.
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Office Administrator
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An x-ray of the ankle was performed on Daniel Way on December 16. Dr. Eberly interpreted the x-ray and dictated his impression, which then became part of the hospital's electronic health record. This impression is ________________________ data.
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unstructured
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Dr. Henderson wrote a progress note in the emergency room note of Lisa Ford. This is an example of _________________ data.
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unstructured
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The progress note of Amy Shaw states that she is a 51-year-old female who has a history of lower back pain following a fall off a ladder in 2007. She has been taking ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs to miss work. Based on her history and the results of the physician's physical exam, his treatment plan is naproxen sodium daily and an order for physical therapy to include TENS treatments with follow-up visit scheduled in four weeks. This is an example of a patient's health _______________________.
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information
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The date of birth on a patient's record is ___________________ data.
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structured
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A zip code would be an example of _______________ data.
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structured
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A record that contains a person's health history, allergies, current complaints, past medical and surgical history, and a listing of current medications, but is not considered a legal health record is a/an:
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personal health record
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Typically, paper health records are maintained how?
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filed in folders in numeric or alphabetic order
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From which medium is the image above taken?
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electronic health record
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Entering data into a computer system is also known as ________________ data.
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capturing
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When collecting data on a computer or retrieving data from a computer, the screen becomes the replacement for ______________.
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paper
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The capturing of data about a patient begins at what point?
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when the patient calls for an appointment or arrives at the hospital for care
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The ____________ allows for the exchange of information among caregivers, insurance companies, employers, and others, when there is a need for information.
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Electronic Health Record (EHR)
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Of the following, which is not a core function of the EHR as defined by the Institute of Medicine?
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filing of insurance claims
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Information that identifies the patient in any way is known as _________________.
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protected health information
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The ________________________ is published by the federal government and includes all actions taken by any government entity on a given date.
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Federal Register
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The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the _______________________.
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American Recovery and Reinvestment Act
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\"A set of standards, services, and policies that enable the secure exchange of health information over the Internet\" is known as:
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National Health Information Network
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In order to send and accept diagnosis codes using ICD-10-CM, which version of the HIPAA Code Set rule was effective as of January 1, 2012?
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version 5010
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This entity was founded in 2004 to certify electronic health records.
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Certification Commission for Health Information Technology
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A unique identifier that is required on claim forms and identifies the care provider or group practice submitting the claim is the:
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National Provider Identifier number
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In a physician's office, the equivalent of a hospital's master patient index is a/an:
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patient list
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In a hospital setting, when the patient presents for care he/she is:
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registered
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The hospital equivalent to practice management software used in the physician's practice is known as:
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Registration, Admission, Discharge, Transfer System
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John Smith was admitted to Memorial Hospital on June 6 and died while in the hospital, on June 10. The action taken on June 10 was a/an:
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discharge
