ExamName___________________________________MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)Which of the following statements is true?1)A)A patient's account number is always the same as his or her patient ID.B)A guarantor is a person who is responsible for paying any portion of a healthcare bill that isnot covered by insurance.C)A patient must be the guarantor of his or her own account with a healthcare provider.D)A patient cannot be the beneficiary of a health plan unless he or she is also the policy holder.Answer:BExplanation:A)B)C)D)2)When patients sign an assignment of benefits document, they2)A)are waiving their privacy rights under HIPAAB)are authorizing their health plan to pay the healthcare provider directly.C)are agreeing to serve as guarantor of their account with a healthcare provider.D)are indicating that their health insurance coverage extends to their dependents.Answer:BExplanation:A)B)C)D)3)According to the IOM, the ultimate goal of computerizing medical records is:3)A)To safeguard the privacy of patients' medical information.B)To create a longitudinal log of patients' medical encounters.C)To simplify result and order management for medical practitioners.D)To improve the delivery of safe, quality care focused on patients' health.Answer:DExplanation:A)B)C)D)1

4)In which of the following scenarios is the EHR functioning in an order management capacity, asdescribed by the IOM?4)A)After a patient undergoes laboratory testing to determine his serum cholesterol levels, theelectronic health records system automatically emails him a copy of the test results.B)Each week, a hospital's electronic health records system transmits information regarding allnew cases of reportable diseases to the county health department.C)Whenever a particular drug is recalled, a practice's electronic records system generates a listof all patients who are taking this medication so they can be immediately notified of therecall.D)When a physician types the prescribed dose of a particular medication into a patient'selectronic health record, the system generates a warning stating that this dose is dangerouslyhigh and may have been entered incorrectly.Answer:DExplanation:A)B)C)D)5)Which of the following statements is accurate?5)A)The EHR includes information on a patient's physical health but not his or her mental health.B)The EHR focuses only on information related to patients' past and present health.C)The federal government proposed its own definition of EHR in the Health InsurancePortability and Accountability Act.D)The EHR encompasses not just stored data, but also the functional benefits of having suchdataAnswer:DExplanation:A)B)C)D)6)A particular healthcare appointment lasts 60 minutes total and requires 75% effort on the part ofthe physician. Which of the other appointments listed below could be scheduled during the sameperiod?6)A)An appointment that lasts 30 minutes and requires 50% effortB)An appointment that lasts 60 minutes and requires 30% effortC)An appointment that lasts 45 minutes are requires 40% effortD)An appointment that lasts 25 minutes and requires 85% effortAnswer:AExplanation:A)B)C)D)2

7)Which federal regulatory body is charged with developing a strategic plan to guide the"nationwide implementation of interoperable health information technology in both the public andprivate healthcare sectors"?7)A)ONCB)CMSC)HITECHD)AHRQAnswer:AExplanation:A)B)C)D)8)Which of the following statements is true?8)A)Point-of-care documentation often results in decreased accuracy of patient data.B)Point-of-care documentation offers no clear benefit with regard to patient education.C)Point-of-care documentation lowers the overall cost of healthcare delivery.D)Point-of-care documentation is less efficient than traditional documentation but leads toincreased patient compliance.Answer:CExplanation:A)B)C)D)9)One benefit of electronic charting (as compared to paper charting) is that9)A)it permits only physicians and registered nurses to view a patient's chart.B)it permits multiple providers to access a patient's chart at the same time.C)it eliminates the need for providers to exercise clinical judgment.D)it decreases the need for patient counseling and education.Answer:BExplanation:A)B)C)D)10)Physicians who use electronic rather than paper charting typically10)A)spend less time revising prescriptions.B)spend more time determining and documenting billing codes.C)spend more time finalizing exam notes at the end of the workday.D)have less time available for patient education and counseling.Answer:AExplanation:A)B)C)D)3

11)Which of the following pieces of information wouldnotbe appropriate to record during the patientregistration process?11)A)HIPAA privacy preferencesB)Emergency contact informationC)Percent effort for an appointmentD)Preferred languageAnswer:CExplanation:A)B)C)D)12)According to the IOM, all of the following are core functions of an electronic health recordexcept:12)A)Enhancing patient support and educationB)Decreasing outside access to patients' health informationC)Increasing the efficiency of administrative processesD)Improving order managementAnswer:BExplanation:A)B)C)D)13)As compared to an outpatient chart, an inpatient chart likely13)A)covers a longer span of time.B)has fewer people accessing it.C)contains a greater quantity of data.D)consists largely of the physician's exam notes.Answer:CExplanation:A)B)C)D)14)Which of the following is a societal trend that has helped contribute to increased use of EHR?14)A)Increased specialization among medical care providersB)Rising public concern about the security of electronic dataC)Patient reluctance to rely on health information obtained through the InternetD)Americans' decreasing tendency toward relocationAnswer:AExplanation:A)B)C)D)4

15)How did the HITECH Act of 2009 help promote EHR adoption?15)A)It authorized the CMS to make incentive payments to consumers who select healthcareproviders that use a certified EHR.B)It authorized the ONC to make incentive payments to consumers who select healthcareproviders that use a certified EHR.C)It authorized the ONC to make incentive payments to healthcare providers that use a certifiedEHR.D)It authorized the CMS to make incentive payments to healthcare providers that use a certifiedEHR.Answer:DExplanation:A)B)C)D)16)Information regarding a patient's self-described symptoms would be recorded in what portion ofthe chart?16)A)PlanB)ObjectiveC)AssessmentD)SubjectiveAnswer:DExplanation:A)B)C)D)17)Which of the following is an example of point-of-care documentation?17)A)A physician records notes on a patient encounter shortly after the patient leaves the office.B)A nurse enters a patient's vital signs while standing at the bedside.C)A nurse enters patient encounter notes at the end of a shift.D)A physician reviews test results prior to a patient's office visit.Answer:BExplanation:A)B)C)D)18)As compared to paper medical records, electronic health records offer18)A)similar levels of portability.B)decreased legibility.C)increased liability.D)increased searchability.Answer:DExplanation:A)B)C)D)5

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19)Which of the following isnota social force that is driving the adoption of EHR?19)A)Consumers' increasing expectation that health information be available both quickly andsecurely over the InternetB)Patients' increasing tendency to remain in the care of a single healthcare provider for a periodof several years or moreC)Widespread concern about the number of preventable medical errors that occur each year inthe United StatesD)Employer and insurer concerns about the connection between poor quality care and risinghealthcare costsAnswer:BExplanation:A)B)C)D)20)Which of the following statements is accurate with regard to patient charts?20)A)An outpatient chart usually focuses on treatment of a specific ailment for which the patienthas sought care.B)A unique inpatient chart is created for each of a patient's hospital stays.C)An outpatient chart consists primarily of the physician's orders and nurses' notes indicatingthe patient's response.D)An inpatient chart contains less patient data because it covers a shorter period of time.Answer:BExplanation:A)B)C)D)6

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ExamName___________________________________MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)When entering a test order into a patient's EHR, a clinician receives an alert indicating that an ABNis required. In this scenario, the clinician must1)A)notify the patient that the test will be fully covered by Medicare, then have the patient sign aform indicating that he has received this information.B)notify the patient that Medicare requires a second follow-up test also be performed, thenhave the patient sign a waiver indicating that he has been informed of this requirement.C)notify the patient that the test will not be covered by Medicare, then have the patient sign awaiver indicating that he has received this information and agrees to pay for the test.D)notify the patient that Medicare considers this test unnecessarily dangerous, then have thepatient sign a form indicating that he understands the associated risks.Answer:CExplanation:A)B)C)D)2)Which of the following statements is true with regard to patient-entered data?2)A)Patients who enter their own data are often better prepared for their visits with clinicians.B)Patient-entered data tends to not accurately reflect a patient's complaints.C)Use of patient-entered data offers no time savings to clinicians.D)Patient-entered data does not require clinician review prior to being merged into the EHR.Answer:AExplanation:A)B)C)D)3)Medcin differs from SNOMED-CT in that3)A)it contains only two types of semantic relationships:Is-AandAttribute.B)it was designed to classify medical information for research purposes.C)its nomenclature is purely a codified list of terms.D)it was originally developed for point-of-care use by clinicians.Answer:DExplanation:A)B)C)D)4)Which of the following EHR code sets is used to codify the discrete elements of nursing practice?4)A)RxNormB)LOINCC)CCCD)UMLSAnswer:CExplanation:A)B)C)D)1

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5)Which of the following is a major benefit of codified EHR?5)A)Use of codes eliminates the need for fielded data in patients' medical records.B)Use of codes allows each clinician to develop a unique system for indicating specific findingsor treatments.C)Use of codes allows for more precise identification of a clinician's findings.D)Use of codes eliminates the need for digital image or text data in patients' medical records.Answer:CExplanation:A)B)C)D)6)When entered into an EHR, text-based lab results6)A)are harder to search than image-based lab results but easier to analyze than coded lab data.B)are easier to search than image-based lab results but more difficult to analyze than coded labdata.C)are harder to search than coded lab data but easier to use in trend analysis.D)are easier to search than coded lab data but harder to use in trend analysis.Answer:BExplanation:A)B)C)D)7)Which of the following statements is true with regard to the capture and recording of EHR data?7)A)Digital images are rarely included in a patient's EHR.B)Modern computer systems eliminate the need for human involvement in the scanning andcataloging of EHR dataC)It is preferable to import word processing files rather than print and scan them.D)Text data must be codified before it can be imported into an EHR.Answer:CExplanation:A)B)C)D)8)Within SNOMED-CT, which type of relationship connects concepts from two different hierarchies?8)A)AnAttributerelationshipB)ACategoryrelationshipC)ALink-TorelationshipD)AnIs-ArelationshipAnswer:AExplanation:A)B)C)D)2

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9)A protocol is9)A)a list of medications that are covered by a particular health insurance plan.B)a standard plan of therapy that has been established for a particular condition.C)a set of instructions for performing a specific action within an EHR system.D)a set of standard warnings associated with a specific medication.Answer:BExplanation:A)B)C)D)10)Which of the following code sets is primarily used to record information related to laboratory testorders and results?10)A)CCCB)LOINCC)MedcinD)SNOMED-CTAnswer:BExplanation:A)B)C)D)11)Use of a codified EHR11)A)makes it more difficult for clinicians to identify trends in a patient's health.B)makes it harder for clinicians to consult drug formularies prior to writing prescriptions.C)decreases the likelihood that patients will not receive recommended preventive screenings.D)complicates the process of drug utilization review.Answer:CExplanation:A)B)C)D)12)Which of the following functions wouldnotbe part of a computerized DUR program?12)A)Checking a patient's prescription record to determine whether there is the potential for anydrug-drug interactionsB)Comparing a patient's prescription record against a list of similar drugs to determine whethercheaper medication alternatives existC)Determining whether the prescribed dose of a drug falls within recommended guidelinesD)Reviewing a patient's records for any allergies that may be aggravated by a new drugAnswer:BExplanation:A)B)C)D)3

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13)In which of the following scenarios is the EHR system functioning in a decision-support capacity?13)A)An EHR system links a physician to the latest evidence-based guidelines for treating aparticular disease.B)An EHR system notifies a physician that an ABN is required for a particular procedure.C)An EHR system reminds a nurse that she has forgotten to obtain all of a patient's vital signsduring an office visit.D)An EHR system automatically emails a patient a copy of her latest lab results.Answer:AExplanation:A)B)C)D)14)Most EHR systems issue immunization alerts based on14)A)recommended schedules developed by the CDC and the state department of health.B)the patient's preferred vaccination timeline.C)the individual clinician's preferred vaccination timeline.D)recommended schedules developed by the World Health Organization.Answer:AExplanation:A)B)C)D)15)A(n) ________ is a message or reminder that is automatically generated by an EHR system.15)A)alertB)cautionC)conditionD)warningAnswer:AExplanation:A)B)C)D)16)Which of the following statements accurately describes coded data?16)A)Coded data is a form of discrete data but not a form of fielded data.B)Coded data is the most difficult type of data for a computer to search and retrieve.C)Coded data is usually obtained by importing text files from outside sources.D)Coded data is fielded data that contains codes in addition to or in place of descriptive text.Answer:DExplanation:A)B)C)D)17)________ is the electronic transmission of healthcare-related data among facilities, healthinformation organizations, and government agencies.17)A)HIEB)DICOMC)HL7D)CDISCAnswer:AExplanation:A)B)C)D)4

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18)Two critical components of health maintenance are18)A)lab result tracking and preventive care screening.B)immunizations and drug utilization review.C)preventive care screening and immunizations.D)drug utilization review and lab result tracking.Answer:CExplanation:A)B)C)D)19)What are the three main forms of EHR data?19)A)Discrete data, diagnostic images, and scanned documentsB)Digital images, text files, and discrete dataC)Digital images, fielded data, and coded dataD)Diagnostic images, scanned documents, and text filesAnswer:BExplanation:A)B)C)D)20)In which of the following scenarios is the employee cataloging an image in an EHR?20)A)An employee uses a scanner to create a digital version of a printed document, then importsthe digital file into a patient's EHR.B)An employee assigns descriptive keywords to a image file that has been imported into apatient's EHR.C)An employee deletes a digital image from a patient's EHR and replaces it with textual datathat conveys the same information.D)An employee receives a digital image from a patient's radiologist, then imports the image fileinto the patient's EHR.Answer:BExplanation:A)B)C)D)5

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ExamName___________________________________MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)Clicking the View button on the toolbar lets you choose from what three display options?1)A)Expanded view, concise view, and outline viewB)Expanded view, condensed view, and heading viewC)Entry view, expanded view, and heading viewD)Entry view, concise view, and outline viewAnswer:DExplanation:A)B)C)D)2)Which of the following vital signs has more than one possible unit of measure?2)A)Blood pressureB)Heart rateC)TemperatureD)Oxygen saturationAnswer:CExplanation:A)B)C)D)3)Which of the following statements is true with regard to setting an encounter date in the StudentEdition?3)A)When typing an encounter date into Quippe, you must use the format YY/DD/MM.B)When you create an encounter in Quippe, the month, day, and year automatically default toyour computer's date settings.C)When entering an encounter date in Quippe, there is no need to type a slash between themonth and day or between the day and year.D)There are three different methods for entering an encounter date in Quippe.Answer:BExplanation:A)B)C)D)1

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4)To remove a clinical concept from an encounter note, you should4)A)click on the concept within the appropriate section of the workspace, then click the blueQuippe icon button and select Remove from the drop-down menu that appears.B)double-click on the concept within the appropriate section of the workspace, then selectRemove from the drop-down menu that appears.C)click on the concept within the appropriate section of the workspace, then click the Toolsbutton and select Delete from the drop-down menu that appears.D)click on the concept within the appropriate section of the workspace, then click the Actionsbutton and select Delete from the drop-down menu that appears.Answer:DExplanation:A)B)C)D)5)Clicking the Tools button allows you to5)A)access the E&M Calculator.B)change the workspace display.C)open the Quippe application menu.D)search the Medcin knowledge base.Answer:AExplanation:A)B)C)D)6)Clinical concepts used in the Plan section of a SOAP encounter note are located in which Medcinnomenclature domain?6)A)TherapyB)Physical examinationC)SymptomsD)Diagnoses, syndromes and conditionsAnswer:AExplanation:A)B)C)D)7)In the Student Edition software,7)A)an unentered clinical finding is considered normal.B)a negative clinical finding is considered normal.C)an unentered clinical finding is considered abnormal.D)a positive clinical finding is considered normal.Answer:BExplanation:A)B)C)D)2

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8)To generate a printable PDF of an encounter note, you should8)A)click the Actions toolbar button, then select Export Data from the list of available options.B)click the blue Quippe icon button, then select Export Data on the drop-down menu thatappears.C)click the Actions toolbar button, then select Create PDF from the list of available options.D)click the blue Quippe icon button, then select Create PDF on the drop-down menu thatappears.Answer:DExplanation:A)B)C)D)9)The Quippe Student Edition software uses which standard EHR nomenclature?9)A)LOINCB)SNOMED-CTC)CCCD)MedcinAnswer:DExplanation:A)B)C)D)10)Details are added to a finding via a pop-up window that is invoked by either10)A)clicking the Tools button on the toolbar or double-clicking on the finding.B)clicking the Actions button on the toolbar or double-clicking on the finding.C)clicking the Actions button on the toolbar or right-clicking on the finding.D)clicking the Tools button on the toolbar or right-clicking on the finding.Answer:CExplanation:A)B)C)D)11)In the Student Edition, to record a clinical concept as a finding, you should11)A)designate the concept as either positive or negative.B)leave the concept in the unentered state.C)drag the concept from the Clinical Concept menu to the Findings window.D)type the name of the concept into the workspace pane.Answer:AExplanation:A)B)C)D)12)If you wanted to indicate that a particular clinical concept was worsening, you would do so usingwhich field in the Details pop-up window?12)A)StatusB)ModifierC)DurationD)OnsetAnswer:AExplanation:A)B)C)D)3

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13)Which of the following statements is accurate?13)A)Information regarding a patient's chief complaint is usually entered by selecting one or moreoptions from a clinical concept menu.B)A chief complaint field is rarely included in encounter templates because it is not part of theCMS recommended standard.C)The CMS requires that a chief complaint field be included in every encounter template.D)Information regarding a patient's chief complaint is usually entered by typing in a free-textnote field.Answer:DExplanation:A)B)C)D)14)How do you select a patient from the New Encounter window?14)A)Scroll through the list of patients in the New Encounter window. Right-click on the name ofthe desired patient, then click Select on the drop-down menu that appears.B)Type the patient's name into the Search portion of the New Encounter window. When thepatient's name appears in the Results box, double-click it with the left mouse button.C)Scroll through the list of patients in the New Encounter window. Click once on the name ofthe desired patient, then click OK.D)Type the patient's name into the Search portion of the New Encounter window. When thepatient's name appears in the Results box, click it once, then select OK.Answer:CExplanation:A)B)C)D)15)How do you add free text details to a finding?15)A)Click on the clinical concept, then click the Actions button and select the Modify option fromthe drop-down menu. In the pop-up window that appears, type the free text into the Statusfield.B)Click on the clinical concept, then click the Actions button and select the Modify option fromthe drop-down menu. In the pop-up window that appears, type the free text into the Notefield.C)Click on the clinical concept, then click the Actions button and select the Detail option fromthe drop-down menu. In the pop-up window that appears, type the free text into the Notefield.D)Click on the clinical concept, then click the Actions button and select the Detail option fromthe drop-down menu. In the pop-up window that appears, type the free text into the Statusfield.Answer:CExplanation:A)B)C)D)4

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16)Which of the following measurements is always considered a vital sign?16)A)Oxygen saturationB)Blood pressureC)HeightD)Respiration rateAnswer:DExplanation:A)B)C)D)17)If a patient takes 18 breaths per minute, you should enter "18" in which field of the Vital Signs tablein the patient's encounter note?17)A)BRB)RRC)DBPD)PRAnswer:BExplanation:A)B)C)D)18)Which toolbar button is used to access and navigate the clinical concepts in the Medcinnomenclature?18)A)ToolsB)ViewC)BrowseD)ActionsAnswer:CExplanation:A)B)C)D)19)The Subjective section of a SOAP encounter note would include information from which Medcinnomenclature domains?19)A)Physical Examination, Symptoms, and HistoryB)Physical Examination and TestsC)Symptoms and HistoryD)History and Physical ExaminationAnswer:CExplanation:A)B)C)D)5

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20)To add information about a patient's exercise habits to an encounter note, you should20)A)click the Browse button on the toolbar, then click the plus symbol next to Concepts, followedby the plus symbol next to History, the plus symbol next to Social history, and the plussymbol next to Habits.B)click the Search button on the toolbar, then click the plus symbol next to Concepts,immediately followed by the plus symbol next to History and the plus symbol next toBehavioral history.C)click the Search button on the toolbar, then click the plus symbol next to Concepts,immediately followed by the plus symbol next to History and the plus symbol next to Socialhistory.D)click the Browse button on the toolbar, then click the plus symbol next to Concepts,immediately followed by the plus symbol next to History and the plus symbol next toBehavioral history.Answer:AExplanation:A)B)C)D)6

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ExamName___________________________________MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)When entering findings using the Yes/No style of check boxes, how would you indicate that apatient doesnothave a reaction to anesthetics?1)A)Click on Y check box for reaction to anesthetics then use the word "no" as a modifier.B)Click on Y check box for reaction to anesthetics.C)Click on N check box for reaction to anesthetics.D)Leave the reaction to anesthetics line unmarked to indicate that there is no reactionAnswer:CExplanation:A)B)C)D)2)How does the Student Edition compare to Medcin-based EHR systems being used in medicalfacilities?2)A)The nomenclature varies but the visual style is the same.B)The systems vary in visual style and nomenclature.C)Both have the same nomenclature and visual style.D)The visual style varies but the nomenclature is the same.Answer:DExplanation:A)B)C)D)3)When using a text macro, what does it mean when portions of the text are highlighted?3)A)They are fields for entering patient consent to procedures.B)Those findings are abnormal.C)They are fields for entering findings and details.D)Those findings are positive.Answer:CExplanation:A)B)C)D)4)Blue text indicates that a finding is4)A)normal.B)absent.C)present.D)abnormal.Answer:AExplanation:A)B)C)D)1

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5)How does one clear a prefix that has previously been entered?5)A)Use the blank row in the drop-down list of the Prefix field of Entry Details.B)Erase the entire entry and re-enter with the correct prefix.C)Use the erase button under the Prefix field of Entry Details.D)Use the correct prefix under the Prefix field of Entry Details.Answer:AExplanation:A)B)C)D)6)How is cigarette use reported?6)A)By using a standard unit of packs per day and then the number of yearsB)By using a standard unit of pack-yearsC)By using drop-down menus to indicate length of time and quantity smokedD)By double-clicking on the finding of "cigarette use"Answer:BExplanation:A)B)C)D)7)When using a text macro, how are findings within the macro entered?7)A)A pop-up window allows all findings to be set at once.B)Each related group should be clicked on and set as a sub-set.C)Each one can only be set individually by browsing through the entire Medcin nomenclature.D)Findings cannot be entered within the text macro.Answer:AExplanation:A)B)C)D)8)When entering findings using the two-button style, what is indicated by clicking the left-mostbutton?8)A)The finding is normal.B)The finding is absent.C)The finding is negative.D)The finding is abnormal.Answer:DExplanation:A)B)C)D)2

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9)When findings have three states, which of the following isnota correct match between state andcolor code?9)A)Normal=blueB)Neutral=grayC)Abnormal=redD)Negative=yellowAnswer:DExplanation:A)B)C)D)10)A patient indicates that she has severe pain. Which of the following would be the next step afterlocating and selecting the finding for pain?10)A)Right-click on pain, and then select the Details tab where the prefix is changed to severe.B)Left-click on pain, and then select the Details tab where the modifier is changed to severe.C)Left-click on pain, and then select the Details tab where the prefix is changed to severe.D)Right-click on pain, and then select the Details tab where the modifier is changed to severe.Answer:DExplanation:A)B)C)D)11)Which of the following is a unique characteristic of the Tobacco and Alcohol Use sections?11)A)Positive findings will result in free text boxes.B)Positive findings will turn purple.C)Positive findings will turn blue.D)Positive findings will result in an entry field for details.Answer:DExplanation:A)B)C)D)12)How would you enter the finding that the patient smoked half a pack of cigarettes each day for 20years?12)A)20 pack-yearsB)5 pack-yearsC)10 pack-yearsD)1/2 pack per day per 20 yearsAnswer:CExplanation:A)B)C)D)3

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Electronic Health Records: Understanding And Using Computerized Medical Records, 3rd Edition Test Bank

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