Deck 7: Privacy, Security, Confidentiality, and Legal Issues

Question 1

In what screen are care plans created and selected?

A) Office Visit
B) Patient Chart
C) Patient Instructions
D) New Care Plan

Answer 1

Care plans are created and selected in the Office Visit screen.
Thus the correct option is a.
By opening the Tools menu in the OV screen, the care plan can be accessed. A care plan can be imported in the Care Plan/Guideline window.

Question 2

In the chart evaluation setup, the administrator will define what mandatory criteria for wellness screenings? Select all that apply.

A) Gender (male, female, or either)
B) Age range
C) Actions (test, procedure, or encounter)
D) Recurring

Answer 2

In the chart evaluation set up, the administrator will define mandatory criteria for wellness screenings. Those include: Gender (male, female or either), age range , actions (test, procedure or encounter), and then whether to determine if the criteria has reoccurring accounts or not.
Thus the correct options are a, b, c, and d.
All of the above are mandatory criteria for wellness screenings but also include diagnosis , having lab or medication and high clinical priority.

Question 3

A. What does the chart evaluation feature in SpringCharts allow users to do?
B. What does the message No criterion set indicate?
C. What message window is displayed in the patient's chart when a patient is current with all the chart evaluation items?
D. The chart evaluation feature can be run for a specific patient's chart. How else can the chart evaluation feature be used?

Answer 3

(a)The chart evaluation feature in the SpringCharts allows the users to define preventative health criteria following up with evaluating patient's charts. This is with the hope that the user is checking whether they meet the criteria. SpringCharts is an example of a CDS tool.
(b)The message No Criterion Set indicates that chart evaluations have not been set up on the SpringCharts server. This occurs within the Evaluation Chart window.
(c)The message window that is displayed in the patient's chart when a patient is current with all the chart evaluation items is the Evaluate Chart window. Prior to this window, the message Pt up to date with recommendations appears.
(d)Since the chart evaluation feature can be run for a specific patient's chart, the chart evaluation feature can also be used by instructing the program to run the entire patient database for all evaluated items within the chart. This can locate patients who are not up to date with wellness screenings.

Question 4

Once a practitioner attaches a plan of care in the Office Visit screen, it becomes:

A) A temporary document that is deleted after 90 days
B) A permanent part of the office visit note
C) Unusable-a care plan cannot be attached to an office visit note
D) Linked to the diagnosis, lab, and medication

Question 5

Match the terms with the definitions to be listed below.
_____ 1. Superbill
_____ 2. Wellness screenings
_____ 3. Care plans and practice guidelines
_____ 4. Chart evaluation
_____ 5. Secondary insurance
_____ 6. Patient Instructions Manager
_____ 7. NGC
_____ 8. CDS
_____ 9. Well patient visit
_____ 10. FMHX
_____ 11. Draw program
_____ 12. RTF
A. A health insurance plan that pays for some of the patient's medical expenses that primary health insurance does not pay, for example, the deductible and co-payments.
B. A feature in which patient instructions can be modified and new ones created.
C. A comprehensive database of evidence-based practice guidelines.
D. An EHR integrated system designed to assist physicians and other health professionals with decision-making tasks concerning the healthcare of patients.
E. Specific documents that provide a "road map" to guide all involved with a patient's care.
F. Diagnoses from this section of the patient's face sheet contain health information about a patient's close relatives and can be linked to wellness screening criteria.
G. Periodic medical checkups to test for or inoculate against significant diseases.
H. A feature in the Tools menu of the Office Visit screen that enables the provider to illustrate procedures on built-in templates.
I. A SpringCharts feature used to establish criteria for medical checkups and appraise patients' charts for needed health screenings and tests.
J. Format in which new patient instructions must be created in order to to save into SpringCharts.
K. A routine patient encounter that may include an annual Pap smear and be Record ed in an office visit note.
L. A panel in SpringCharts that contains codes that can be added to the routing slip for billing purposes.

Question 6

The National Guidelines Clearinghouse website contains:

A) National conference dates on a centralized calendar for physicians
B) Detailed clinical information for nurses only
C) Numerous medical treatment plans
D) Electronic prescriptions from physicians across the nation

Question 7

A. All ordered tests in the OV note are also sent to a particular area of the HER program, where they wait for the results to be posted. What is this area called?
B. What is created within the EHR when a test must be conducted at an outside testing facility?

Question 8

The Draw program feature of SpringCharts gives providers the ability to:

A) Document a patient's wounds, injuries, skin disorders, and pain sources.
B) Enable young patients to draw for psychological testing.
C) Doodle while they wait for the MA to finish with the patient.
D) Store documents in the patient's filing cabinet.

Question 9

A. What items are setup in the E M Coder in order for the correct E M code to be recommended in the Routing Slip window?
B. What areas of the SOAP note is examined by the E M Coder to locate key words which will aid in determining the correct E M code recommendation?

Question 10

Key terms and phrases are set up in the E M Coder on the SpringCharts server. The program analyzes the review of systems and the exam verbiage in the OV note for these terms and then gives the provider credit for reviewing the body areas. The number of body areas examined affects:

A) The level of E M code recommended by the program
B) The price of the OV visit
C) The number of diagnoses assigned
D) The number of items selected from the superbill

Question 11

A. What is the purpose of the superbill?
B. What two items appear in the superbill under each category heading?

Question 12

The ONC requires that all certified HER programs have the function of identifying patient-specific educational resources based on:

A) Whether the patient requests an instruction sheet or not
B) Their availability on the NGC website
C) Whether the patient is over 65 years of age or under 5 years of age
D) Identifiable diagnoses, labs, procedures, or medications of the patient

Question 13

A. To import an existing patient instruction document into SpringCharts, it needs to be saved in what format?
B. In what screen are patient instruction sheets accessed for the patient?
C. To which items are patient instructions mapped, causing the EHR program to trigger an Information Available note for the clinician?

Question 14

SpringCharts enables the user to import what type of document into the patient's file cabinet?

A) Only.pdfs
B) Only Microsoft files:.doc,.xls, and.ppt
C) Any type of file
D) Documents transmitted via a certified HER program

Question 15

A. What type of information can be retrieved from the National Guidelines Clearinghouse?
B. What information does a care plan include?

Question 16

Use your critical-thinking skills to answer the following questions.
Describe a situation in a medical office in which an MA would order a test for a patient before the patient is seen by the physician.

Question 17

A. In what menu is the Draw feature located in the Office Visit screen?
B. Where is the draw item stored in the SpringCharts EHR program?

Question 18

Use your critical-thinking skills to answer the following questions.
The File Cabinet Document feature allows the user to import many different types of documents into a patient's chart. How would you store a general form, such as the original medical release form, unrelated to any specific patient?

Question 19

A. Where are File Cabinet Documents stored?
B. What types of documents and fi les can be imported through the File Cabinet Documents window?
C. To view a document or file that has been imported into SpringCharts, what must be installed on the computer or workstation on which the file is opened?

Question 20

Use your critical-thinking skills to answer the following questions.
The physician has chosen two diagnoses, a procedure, and an injection as part of the OV note. These billable items have been automatically added to the routing slip. The physician has also chosen an E M code for the routing slip. The provider realizes that a venipuncture can also be added to the routing slip. What is the best way for the provider to add this charge to the routing slip?

Question 21

Patient instructions and educational documents can be created in SpringCharts or imported into the program. Which screen in the program can these documents be accessed for printing or e-mailing?

A) Office Visit screen
B) Patient Chart screen
C) Practice View screen
D) Edit menu

Question 22

What type of codes are displayed on the customized superbill that are not usually selected within the Office Visit screen?

A) Diagnosis
B) Procedure
C) Additional and ancillary
D) Evaluation Management

Question 23

What type of code in the E M Coder helps the physician determine the correct code for office visit encounters?

A) Diagnosis
B) Procedure
C) Additional Ancillary
D) Evaluation Management

Question 24

What three items can be chosen in the chart evaluation wellness screenings that will create a High Clinical Priority message in the OV screen?

A) Encounter, lab, medication
B) Gender, age, procedure
C) Test, procedure, encounter
D) Diagnosis, lab, medication

Question 25

What area of the EHR program are ordered tests sent to where they wait for results to be posted?

A) Completed Tests
B) Pending Tests
C) Stored Tests
D) Physician Order Forms