Deck 7: Electronic Health Records

Question 1

This medical nomenclature, a merger of two previous coding systems, was developed by the College of American Pathologists and the United Kingdom's National Health Service.

A) MEDCIN
B) SNOMED-CT
C) LOINC
D) All of the above
E) None of the above

Answer 1

SNOMED-CT

Question 2

The more parts of a medical record that are coded, the less useful the data becomes.

Answer 2

False

Question 3

Electronic health records were previously called:

A) electronic medical records.
B) electronic charts.
C) longitudinal patient records.
D) computer-based patient records.
E) All of the above

Answer 3

All of the above

Question 4

When a code is stored in the EHR, the record is considered:

A) complete.
B) incomplete.
C) codified.
D) fielded.
E) None of the above

Question 5

________ are designed to codify the patient-clinician encounter.

A) Data sets
B) Data fields
C) Data abbreviations
D) Nomenclatures
E) Indexing sets

Question 6

Which nomenclature, a list of medically meaningful findings, was developed for point-of-care usage by the clinician?

A) MEDCIN
B) SNOMED-CT
C) LOINC
D) All of the above
E) None of the above

Question 7

All of the following are core functions of the electronic health record set forth by the IOM, EXCEPT:

A) order management.
B) decision support.
C) health information and data.
D) physician support.
E) administrative processes and reports.

Question 8

An example of a nomenclature is:

A) RHIO.
B) MEDCIN.
C) AHRQ.
D) CPRI.
E) IOM.

Question 9

Findings are also referred to as:

A) clinical observations.
B) data.
C) symptoms.
D) signs.
E) None of the above

Question 10

All of the following are functional benefits of the EHR EXCEPT:

A) physician identification.
B) trend analysis.
C) alerts.
D) decision support.
E) health maintenance.

Question 11

The HITECH Act:

A) mandates an electronic health record by all facilities.
B) authorizes Medicare incentive payments to doctors and hospitals using a certified her.
C) ensures both a paper and electronic medical record for every patient.
D) All of the above
E) None of the above

Question 12

The concept of the electronic medical record was originally introduced in 1991 by the:

A) American Medical Association.
B) American Medical Record Association.
C) Institute of Medicine of the National Academies.
D) Agency for Healthcare Research and Quality.
E) Computer-based Patient Record Institute.

Question 13

LOINC standardizes codes for:

A) medical diagnoses.
B) radiology tests.
C) laboratory tests.
D) clinical findings.
E) All of the above

Question 14

Discrete data in an EHR may be subcategorized into:

A) fielded data.
B) coded data.
C) informative data.
D) Both A and B
E) Both B and C

Question 15

The Health Information Technology for Economic and Clinical Health Act was signed into law by:

A) President Barack Obama.
B) President George W. Bush, Jr.
C) President Bill Clinton.
D) President George W. Bush, Sr.
E) None of the above

Question 16

The ________ was given $50 million by Congress to support efforts to reduce medical errors.

A) Institute of Medicine of the National Academies
B) Computer-based Patient Record Institute
C) American Health Information Management Association
D) Agency for Healthcare Research and Quality
E) American Medical Association

Question 17

Nomenclatures are:

A) types of EHRs.
B) EHR coding systems.
C) abstracts.
D) data fields.
E) short abbreviations.

Question 18

Which of the following organizations identified three key criteria for electronic health records that include capturing data, integrating data, and providing decision support?

A) American Health Information Management Association
B) Institute of Medicine of the National Academies
C) Agency for Healthcare Research and Quality
D) Computer-based Patient Record Institute
E) American Medical Informatics Association

Question 19

The HIPAA Security Rule provides protection for all personally identifiable health information stored in an electronic format.

Question 20

Which of the following statements in NOT true regarding Leapfrog?

A) It was formed by a group of employers.
B) It created a strategy that tied the purchase of group health insurance benefits to quality care standards.
C) It promoted CPOE as a means of reducing errors.
D) All of the above
E) None of the above

Question 21

Which of the following is NOT a function performed by a DUR program?

A) The drug being prescribed is checked with the patient's current medications.
B) The patient's allergy records are checked.
C) The patient's diagnosis history is checked.
D) Ingredients of a drug are checked against the ingredients of a drug already being taken.
E) All of the above are performed by a DUR program.

Question 22

The most common alert systems are implemented with prescription systems.

Question 23

An alert notifying the physician of a drug NOT covered by the patient's insurance is called a(n):

A) formulary alert.
B) insurance alert.
C) prescription alert.
D) pharmacy alert.
E) drug utilization review alert.

Question 24

Which of the following measures prevent medication errors?

A) Physician review of patient allergies
B) Physician consultation of the PDR for drug interactions
C) Medication warnings given to the patient from the pharmacy
D) Use of the Allscripts EHR system by the healthcare facility
E) All of the above

Question 25

The ability of EHR systems to store or quickly locate materials relevant to the findings of the current case is referred to as:

A) location support.
B) data support.
C) decision support.
D) information support.
E) clinician support.

Question 26

The BEST way to ensure that preventative services are delivered appropriately is to:

A) send information on preventative care to patients.
B) educate providers on preventative care.
C) make evidence-based information readily available at the time of the patient visit.
D) hold staff in-services about promoting preventative care.
E) None of the above

Question 27

An example of point-of-care documentation is:

A) entering vital signs at the patient's bedside.
B) dictating a report after the patient leaves the office.
C) writing nursing notes at the end of the shift.
D) completing SOAP notes on all patient visits at the end of the day.
E) All of the above

Question 28

An example of a trend analysis tool is a(n):

A) history and physical.
B) flow sheet.
C) problem list.
D) progress note.
E) social history.

Question 29

Which of the following is an automated patient data-entry component of the EHR in which a patient can enter his or her own data?

A) Instant Medical History
B) Patient Medical History
C) Patient Data History
D) Instant Patient Data
E) Patient Plus

Question 30

Trend analysis can be used to analyze:

A) medication information.
B) laboratory tests.
C) weight.
D) blood pressure.
E) All of the above

Question 31

Documenting patient information in the EHR at the time it is happening is called:

A) traditional documentation.
B) automatic documentation.
C) point-of-care documentation.
D) immediate documentation.
E) time-of-service documentation.

Question 32

Which of the following is NOT an example of decision support?

A) Comparison of medication changes
B) Access to medical references
C) Electronic prescription systems
D) Registration of new patients
E) Protocols

Question 33

An important component of health maintenance is:

A) immunizations.
B) surgical care.
C) preventative care screening.
D) Both A and B
E) Both A and C

Question 34

Health maintenance systems are also known as:

A) healthcare reminder systems.
B) health prevention systems.
C) healthy patient systems.
D) preventative health systems.
E) preventative care systems.

Question 35

Data is entered into the EHR by which of the following methods?

A) It is scanned into the EHR.
B) It is imported from another system.
C) It is automatically generated from other reports.
D) It is entered by the patient.
E) All of the above

Question 36

Adult immunizations are different from immunizations given to children.

Question 37

Computers can use ________ data to compare a patient's immunizations against an immunization schedule to determine which immunizations are needed.

A) coded
B) fielded
C) abstracted
D) missing
E) identified

Question 38

Which of the following is an independent panel of experts that reviews and makes recommendations of clinical preventative services?

A) U.S. Preventive Services Task Force
B) Institute of Medicine of the National Academies
C) Agency for Healthcare Research and Quality
D) College of American Pathologists
E) None of the above

Question 39

Which of the following is a computer program that compares a prescription to a database of drugs in addition to patient medications, allergies, and other related information to reduce prescribing errors?

A) Patient medication review
B) Drug utilization review
C) Patient utilization review
D) Drug and medication review
E) Patient medication and drug utilization review

Question 40

Which of the following is a message or a reminder that is automatically generated by the EHR system?

A) Alarm
B) Notice
C) Observation
D) Alert
E) Remark

Question 41

Multiple providers can access the patient's EHR simultaneously.

Question 42

All of the following statements are true of the search function on most EHRs, EXCEPT:

A) it will perform an alternate word search.
B) it is not able to perform automatic word completion.
C) it identifies related findings in other sections of the nomenclature.
D) it produces a list of findings almost instantaneously.
E) it is standardized in most EHRs.

Question 43

The use of computer interviews ________ the quality of the information presented by the patient.

A) decreases
B) improves
C) changes
D) verifies
E) None of the above

Question 44

The electronic medical record does NOT need to be signed after it is completed.

Question 45

Which of the following statements is NOT true of a standard nomenclature?

A) It allows the physician to select terminology.
B) It saves the physician time typing.
C) It displays several sentences describing the patient's condition once a finding is selected.
D) It creates a codified medical record.
E) It cannot be used for point-of-care data entry.

Question 46

An electronic signature must meet all of the following criteria, EXCEPT:

A) the signer must not be able to deny signing the document.
B) the recipient must be able to confirm that it was signed by the real person.
C) the recipient must be able to confirm the document has not been altered since it was signed.
D) All of the above
E) None of the above

Question 47

________ are subsets of standardized nomenclature.

A) Inventories
B) Lists
C) Files
D) Choices
E) None of the above

Question 48

The Instant Medical History program can be used by patients:

A) at a kiosk in the waiting room.
B) on the facility's website through the Internet.
C) with a pen-tablet device in the exam room.
D) All of the above
E) None of the above

Question 49

A ________ is used to display a desired group of findings in a presentation that allows for quick entry of information.

A) data sheet
B) list
C) document
D) form
E) text box

Question 50

Lists of tests, treatments, therapies, and plans of care recommended for certain conditions are called:

A) protocols.
B) order sets.
C) standards.
D) Both A and B
E) Both A and C