Test Bank for Using the Electronic Health Record in the Health Care Provider Practice, 2nd E

Test Bank for Using the Electronic Health Record in

the Health Care Provider Practice, 2nd Edition

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Name: ________________________ Class: ___________________ Date: __________ ID: A

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. Which of the following best describes when a treatment plan is generated?
a. Prior to being seen by the provider
b. At the beginning of a visit with a provider
c. During and/or after a visit with the provider
d. Only when a referral is made to a specialty provider

____ 2. Which of the following questions should the treatment plan and treatment notes answer?
a. What action steps will be taken to address the patient抯 problem(s)
b. What service(s) were provided
c. What procedure(s) were performed
d. All of the above

____ 3. Which of the following is the most efficient way of adding the results of diagnostic test to the EHR?
a. Keyed data entry
b. Document scanning
c. Electronic feed from a test instrument
d. Cross-referencing a paper document

____ 4. Interoperability between LOINC terminology standard and an EHR assist in establishing what type of
data exchange?
a. Lab results c. Surgical reports
b. Pharmacy alerts d. Appointment reminders

____ 5. Which of the following individuals may be involved in the collaborative development of a patient抯
treatment plan?

a. Patient c. Patient抯 representative

b. Provider d. All of the above

____ 6. To support the treatment plan, the EHR system must be capable of which of the following?
a. Automatically transmitting the information to the third-party payer
b. Capturing the details of similar treatment plans for comparison
c. Transmitting orders specified in the treatment plan to the appropriate health care
practitioner
d. Accepting a direct feed of results reporting from clinical information systems

____ 7. Which of the following items is least likely to appear on a treatment plan?
a. Instructions for a low-sodium diet c. Demographic information
b. A prescription for Lipitor d. A referral for a cardiology consult

____ 8. A medical office would use a PMS to support which of the following functions?
a. To schedule a procedure with a health care provider
b. To transmit lab data to the EHR
c. To send a prescription to a pharmacy electronically
d. To create a treatment plan for a patient

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Name: ________________________ ID: A

____ 9. A health care provider is most likely to find which of the following in her daily task list within an EHR
system?
a. A prescription c. A treatment plan
b. A patient appointment d. A referral

____ 10. A patient抯 primary care physician informs the patient that he needs to see a dermatologist. Which of the
following information must 搕ravel? from the primary care provider setting to the dermatology setting?
a. A referral letter c. A continuity of care document
b. A continuity of care record d. All of the above

____ 11. 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:
a. information related to the patient抯 problem
b. information about the medication the patient is taking
c. information about how to contact other patients with the same condition
d. information about interpreting the patient抯 lab results

____ 12. 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?
a. Problem list c. Medication allergy list
b. Medication list d. All of the above

____ 13. Which of the following statements about an ambulatory EHR product is true?
a. National content standards specify what data must be included in the treatment plans.
b. Overall, most ambulatory health care providers include the same data content in their
treatment plans.
c. An EHR product must be flexible to enable a health care provider to define the specific
data content it needs.
d. None of the above statements are true.

____ 14. Which of the following components of an EHR product are the least customizable?
a. Documentation of orders c. Documentation of procedures
b. Documentation of treatment d. Documentation of results

____ 15. Where within a SOAP-formatted treatment note in an EHR system would the physician document a
patient抯 treatment?
a. The 揝 ? section c. The 揂 ? section
b. The 揙 ? section d. The 揚 ? section

____ 16. 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?
a. The system develops a treatment plan for the patient as the exam note is created.
b. Dr. Kimble must open a new treatment plan template once he has completed the
assessment.
c. Dr. Kimble creates a treatment plan as one of the items in the existing template.
d. The system enables Dr. Kimble to dictate his treatment plan and links the file to the
exam note.

____ 17. A physician has created an order for a patient within an EHR system. What happens as the next step in
this process?
a. A medical assistant inputs a status report into the EHR.
b. The physician electronically signs the order.
c. The order goes to the daily task list of the appropriate staff member.
d. The EHR lists the order as open and pending.

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Name: ________________________ ID: A

____ 18. Which of the following individuals within a medical office is least likely to act on an 搊 pen? order?
a. A medical assistant c. A nurse
b. A physician d. A scheduling assistant

____ 19. A physician will use a(n) ________ to document the outcomes of a therapy.
a. order entry template c. treatment note
b. results report d. care plan

____ 20. Which of the following is the best way to improve the completeness of a procedure note within an EHR
system?
a. Use free text c. Use dictation
b. Use a template d. Use multiple sources

____ 21. 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?
a. Via an electronic feed from the imaging center to the practice抯 EHR system
b. Via an e-mail attachment sent by the radiologist to the practice.
c. Via a scan of the results report and a manual update of the EHR order
d. None of the above

____ 22. Which of the following statements about the Continuity of Care Record (CCR) is correct?
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

____ 23. Which of the following is not an example of electronic data interchange (EDI)?
a. direct faxing c. voice mail
b. secure e-mail d. All of the above are examples

____ 24. When creating an order for a patient procedure within an EHR template, a health care provider needs to
enter the _____.
a. referral letter c. procedure notes
b. order details d. results report

____ 25. The steps a health care provider intends to follow to address a patient抯 problem must be identified in
which of the following?
a. Diagnostic order c. Treatment plan
b. Problem list d. Medication list

____ 26. When implemented by an EHR system, which of the following ONC-ATCB Meaningful Use Criteria
most directly affects the patient?
a. The ability of the EHR to incorporate lab test results
b. The ability of the EHR to record, store, and retrieve medication orders
c. The ability of the EHR to implement clinical decision support rules
d. The ability of the EHR to create discharge instructions

____ 27. 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 ________.
a. the patient抯 medication allergy list c. a summary of the patient抯 record
b. digital images of the patient抯 x-rays d. information regarding procedures

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Name: ________________________ ID: A

____ 28. Which of the following accreditation organization requires that the treatment plans and therapeutic
services provided to the patient be documented in the ambulatory patient record?
a. AAAHC c. The Joint Commission
b. NCQA d. All of the above

Matching

Match each item with the correct statement below.

a. Results reporting
b. Procedure notes
c. Order details
d. Order templates
e. Direct faxing
f. Treatment notes
g. Joint Commission Record Content (R.C.) standards
h. Referral letter
i. Electronic data interchange (EDI)
j. Procedure notes ? template
k. Daily task list
____ 1. Designation of work that needs to be completed during scheduled hours by an employee of a practice
____ 2. Transfer of health care provider information from one organization to another via facsimile
____ 3. Transfer of health care provider information from one organization to another electronically
____ 4. Guidelines that are part of the Joint Commission accreditation process that address the area of ambulatory
care health records
____ 5. Specific items that must be entered by a health care provider to made an order complete
____ 6. The format of structured data entry items required to complete a medical order
____ 7. Unstructured writing by a health care provider describing the patient encounter
____ 8. Structured format documentation by a health care provider describing the patient encounter
____ 9. Request from one health care provider to another to provide specialized services to a patient, including
transfer of information from one practice to another
____ 10. Communication of the findings associated with a completed diagnostic test order
____ 11. Unstructured writing by a health care provider describing the patient encounter

Short Answer

1. List three examples of what might be specified in a treatment plan.

2. List the four common applications within a PMS system.

3. Briefly explain how an EHR system integrated with a PMS contribute to implementing a treatment plan.

4. List three common methods used for transmitting a diagnostic or treatment order from one health care
practice抯 EHR system to an external health care provider.

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Name: ________________________ ID: A

5. Provide three examples of ONC-ATCB Meaningful Use certification criteria that are focused on
supporting the implementation activities associated with the treatment plan.

6. Give two examples of how an EHR system may improve care from the patient抯 perspective.

5
 ID: A

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Answer Section

MULTIPLE CHOICE

1. ANS: C PTS: 1
2. ANS: D PTS: 1
3. ANS: C PTS: 1
4. ANS: A PTS: 1
5. ANS: D PTS: 1
6. ANS: C PTS: 1
7. ANS: C PTS: 1
8. ANS: A PTS: 1
9. ANS: B PTS: 1
10. ANS: D PTS: 1
11. ANS: C PTS: 1
12. ANS: D PTS: 1
13. ANS: C PTS: 1
14. ANS: A PTS: 1
15. ANS: D PTS: 1
16. ANS: C PTS: 1
17. ANS: B PTS: 1
18. ANS: B PTS: 1
19. ANS: C PTS: 1
20. ANS: B PTS: 1
21. ANS: C PTS: 1
22. ANS: D PTS: 1
23. ANS: C PTS: 1
24. ANS: B PTS: 1
25. ANS: C PTS: 1
26. ANS: D PTS: 1
27. ANS: B PTS: 1
28. ANS: D PTS: 1

MATCHING

1. ANS: K PTS: 1
2. ANS: E PTS: 1
3. ANS: I PTS: 1
4. ANS: G PTS: 1
5. ANS: C PTS: 1
6. ANS: D PTS: 1
7. ANS: B PTS: 1
8. ANS: J PTS: 1
9. ANS: H PTS: 1
10. ANS: A PTS: 1

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 ID: A

11. ANS: F PTS: 1

SHORT ANSWER

1. ANS:
Answers will vary - here are some examples:
Patient education
Medications
Laboratory tests
Referral
Non-surgical procedure
Surgical procedure

PTS: 3
2. ANS:
Patient demographics, including their health insurance
Appointment scheduling
Charge capture and billing
Reporting

PTS: 4
3. ANS:
The workflow gains efficiency by electronically linking the treatment plan to those practitioners who
actually implement the plan.

PTS: 1
4. ANS:
Direct secured e-mail
Direct fax out of the EHR
Print; hardcopy printed and then delivered by regular fax, mailed, or hand delivered

PTS: 3
5. ANS:
Students? answers should include at least three of the following:
Incorporate laboratory test results
Patient-specific education resources
Electronic prescribing
Patient Reminders
Computerized provider order entry
Clinical decision support
Electronic copy of discharge instructions
Exchange clinical information and patient summary record

PTS: 3

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Test Bank for Using the Electronic Health Record in the Health Care Provider Practice, 2n

ID: A

6. ANS:
Students? answers may vary, but may include any two of the following--
Receiving discharge instructions makes following the treatment plan easier.
Receiving patient education materials at discharge makes following the treatment plan easier.
Electronic transmission of prescriptions to a pharmacy saves time.
Electronic transmission of patient information between health care providers, including referrals and
pertinent clinical information, makes care more efficient.

PTS: 2

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