Reference no: EM131082221

Questions 1 to 20: Select the best answer to each question. Note that a question and its answers may be split across a page break, so be sure that you have seen the entire question and all the answers before choosing an answer.

1. If a patient believes his or her rights have been violated, that patient may file a complaint with

A. CMS.
B. HHS.
C. AHIMA.
D. OCR.

2. How can a new patient be entered in SimChart for the Medical Office?

A. In the billing module
B. Using the Find Patient link
C. In the patient dashboard
D. Searching the Patient Demographics

3. Medical offices submitting claims electronically are called

A. electronic carriers.
B. HIPAA entities.
C. covered claims.
D. covered entities.

4. Security guards are an example of _______ safeguards.

A. privacy
B. technical
C. physical
D. administrative

5. Which of the following is not a documenter of the patient chart?

A. Billing specialist
B. Medical assistant
C. Patient
D. Physician

6. Early medical documentation of present-day posttraumatic stress syndrome was first seen in

A. the plagues of Europe.
B. the Civil War.
C. World War II.
D. the Korean War.

7. An individual who is responsible for recording data in the patient record is called a

A. guarantor.
B. health records clerk.
C. documenter.
D. data entry clerk.

8. Which one of the following items is an example of demographic information?

A. Insurance company name
B. Medications
C. Chief complaint
D. Marital status

9. The review of employee activity within an EHR system, including an examination of file access and modification, is called a/an

A. transcription.
B. authorization.
C. encounter.
D. audit.

10. What nonprofit industry group and consumer reporting agency maintains a database of medical information exchanged by the life, health, and disability insurers that make up its membership?

A. CCHIT
B. Electronic Health Organization
C. Medical Information Bureau
D. Medical Systems Care

11. _______ is a coalition of healthcare organizations that promotes the adoption of interoperable EHRs by healthcare facilities.

A. ONC
B. HHS
C. CCHIT
D. CMS

12. Which one of the following laws would regulate a consumer reporting agency?

A. HIPAA
B. Affordable Care Act
C. Americans with Disabilities Act
D. Fair Credit Reporting Act

13. Which of the following is not an example of student resources in SimChart for the Medical Office?

A. Gradebook overview
B. Submitting an assignment
C. Job readiness
D. Assignment answer key

14. After Kevin's HIV results are in, the doctor asks him to make an appointment to review the results together in a private office setting. This is an example of

A. consent.
B. privacy.
C. confidentiality.
D. anonymity.

15. The record of a patient who hasn't been seen by the provider in three or more years would be considered a/an _______ record.

A. disused
B. closed
C. inactive
D. terminated

16. Which one of the following is an example of a third-party payer?

A. Parent
B. Insurance company
C. Healthcare facility
D. Patient

17. To whom does ownership of the physical medical record belong?

A. The patient
B. The hospital to which the doctor admits
C. The doctor
D. The one who creates and maintains the record

18. ABC Insurance has decided to discontinue Avery's insurance based on information it received from the local consumer reports agency. This situation falls under

A. preexisting condition.
B. statute of limitations.
C. adverse action.
D. anonymity.

19. Front Office, Clinical Care, and Billing and Coding are known as

A. modules.
B. available functions.
C. offices.
D. clinical status.

20. Encryption and decryption technology are examples of _______ safeguards.

A. administrative
B. physical
C. technical
D. privacy

Administrative and Clinical Use of the HER

1. All of the following are core objectives of the meaningful use program except

A. maintenance of an active allergy medication list.
B. implementation of drug-to-drug allergy interaction check.
C. implementation of drug formulary checks.
D. using CPOE.

2. Patient records are classified by all of the following except

A. closed.
B. active.
C. insurance type.
D. inactive.

3. A project (or charter) leader for the move from paper-based to electronic records should

A. be the office manager.
B. be a clinician from the practice.
C. be responsible for financing the EHR project.
D. provide clear direction for staff during the implementation process.

4. A _______ is a set of related tasks needed to complete a step in a business process.

A. work list
B. workflow
C. job description
D. priority list

5. What output device encodes documents in order to transmit them over telephone lines?

A. Modem
B. EHR
C. Fax
D. Email

6. _______ provides a thorough description of the patient's clinical presentation, helps flesh out the patient's yes or no answers to questions about history and review of systems, and describes abnormal findings on physical examination.

A. Overdocumentation
B. EHR template
C. Unstructured data entry
D. Structured data entry

7. Which is not an example of backing up the EHR?

A. Keeping backup procedures at the main office only
B. Using a company that backs up files daily
C. Keeping backup procedures at a secondary location
D. Backing up the EHR frequently throughout the day

8. A user purchases software and installs it on his or her practice's own server. This situation is called

A. network platform.
B. application service provider.
C. client-server model.
D. license ownership.

9. Which one of the following describes a concern with using faxes?

A. They take too long to process.
B. Their encryption can be easily broken.
C. They might be directed to the wrong place.
D. They're too expensive.

10. Which of the following is a core objective added to the Stage 2 meaningful use requirements?

A. Use of secure electronic messaging to communicate with patients
B. Providing clinical summaries for patients at each office visit
C. Documenting smoking status
D. Incorporating clinical lab-test results into EHR as structured data

11. A technology that converts speech into text as the provider speaks into a microphone is known as _______ software.

A. voice-activated
B. speech recognition
C. speech translation
D. voiceover

12. Which of the following is not a goal of the meaningful use incentive program?

A. Improve coordination of patient care
B. Improve the safety and efficiency of EHR systems
C. Increase the cost of EHR systems
D. Maintain security of patient health information

13. Giving two or more patients the same appointment slot with the same provider is called

A. double-booking.
B. multiple slots.
C. no-show.
D. wave scheduling.

14. An office that uses EHR for new patients and paper-based records for established patients is termed a/an _______ office.

A. transitioning
B. legacy
C. hybrid
D. combination

15. Congestive heart disease and asthma are examples of _______ conditions.

A. chronic
B. metastatic
C. primary
D. acute

16. The abbreviation PO means

A. by mouth.
B. as directed.
C. as needed.
D. immediately.

17. What are no-shows?

A. Grounds for terminating the doctor-patient relationship
B. Patients who fail to show up for an appointment and don't call to cancel
C. Patients who are behind in paying for their treatment
D. Patients who fail to cancel an appointment within a 24-hour time period

18. Which of the following is not a guideline for e-visits?

A. E-visits may be offered to new and established patients.
B. Communication must occur over a HIPAA-compliant online connection.
C. The provider should define the time period during which the e-visit will be completed.
D. The provider must document the e-visit.

19. A condition that presents suddenly and is usually severe but of brief duration is a/an _______ condition.

A. chronic
B. acute
C. metastatic
D. primary

20. Which of the following is not a common duty of the front office assistant?

A. Greeting the patients
B. Assisting the patients to the exam room
C. Generating patient letters
D. Creating and maintaining the HER

Reimbursement and Personal Health Records

1. What is an outcomes-based payment model that rewards providers for delivering evidence-based care according to specific standards and for electronically documenting compliance with those standards?

A. PPS
B. P4P
C. PCP
D. PPO

2. The CPT-4 coding system

A. consists of 5-digit codes.
B. consists of 3- to 5-digit codes.
C. is organized by volumes.
D. was developed by the AAMA.

3. A server that provides data transfer and storage space at remote locations is called a

A. patient portal.
B. personal health record.
C. network.
D. host.

4. What method is inexpensive, easy to maintain, and secure, but its chief drawback is the difficulty of sharing information?

A. Online personal health record
B. Paper-based personal health record
C. Personal health record software
D. Individual health record

5. _______ codes are supplemental codes used to help researchers collect data, track illness and disease, and measure quality of care.

A. Category III
B. Category I
C. Category II
D. Volume I

6. _______ codes are temporary codes applied to emerging technology.

A. Category I
B. Category III
C. Volume I
D. Category II

7. Services related to office visits and hospital observation codes are coded from

A. Medicine.
B. Volume I.
C. E/M.
D. Category II.

8. Another name for coding variances is

A. accuracy.
B. ranges.
C. mistakes.
D. descriptions.

9. What ICD-9-CM volume contains codes used by hospitals to report inpatient care?

A. Volume III
B. Volume II
C. Volume IV
D. Volume I

10. The _______ is an electronic claim format used to gather reimbursement from insurance payers for the physician.

A. UB 1500
B. HIPAA 5010
C. CMS 1500
D. CMS 1400

11. Medicare is an example of a

A. third-party payer.
B. guarantor.
C. secondary payer.
D. tertiary payer.

12. Volume 1 of the ICD-9-CM manual contains

A. codes for durable medical equipment used by Medicare.
B. procedural coding for outpatient physician services.
C. a tabular list of diseases.
D. anesthesia codes.

13. _______ is a uniform language for describing procedures and treatments performed by healthcare providers.

A. CPT-4
B. CPT-5
C. ICD-10-CM
D. ICD-9-CM

14. Ultrasound would be coded from

A. Medicine.
B. Radiology.
C. Volume I.
D. E/M.

15. The process of assigning standard numeric or alphanumeric characters to diagnoses, procedures, and treatments is called

A. coding.
B. documentation.
C. sorting.
D. reimbursement.

16. A tetanus injection would be coded from

A. Volume I.
B. Radiology.
C. Medicine.
D. E/M.

17. Which of the following pieces of information is not found on the patient encounter form?

A. Physician's NPI number
B. Codes for diagnosis
C. Patient name
D. Codes for services performed

18. What is a comprehensive electronic or paper-based record of health information controlled by the patient, through which he or she can access, manage, and share confidential health information?

A. Electronic medical record
B. Individual health record
C. Electronic health record
D. Personal health record

19. The ability of separate systems to share information in compatible formats is called

A. social networking.
B. fragmentation.
C. interoperability.
D. populating.

20. MyFitnessPal is an example of a/an

A. encounter form.
B. social network.
C. online food journal.
D. health app.

Electronic Medical Records Final Exam

1. A summary of all the accounting transactions performed during the business day is generated using a

A. patient ledger.
B. deposit slip.
C. day sheet.
D. HIPAA 5010.

2. _______ are a set of rules and standards of conduct that grow from our understanding of right and wrong.

A. Laws
B. Morals
C. Ethics
D. Values

3. A modified hybrid office

A. uses paper records only until the old records can be entered into the EHR.
B. is using practice management software, but not EHR.
C. stores the same record on both the EHR and paper record as a backup.
D. uses EHR for new patients only.

4. A patient complains of pain in his left arm and shoulder. This complaint is what part of a patient encounter?

A. Subjective
B. Assessment
C. Objective
D. Plan

5. What is another name for a patient visit?

A. Documentation
B. Encounter
C. Assessment
D. Evaluation

6. When a user enters an Electronic Health Record, the landing page is

A. Patient ledger.
B. Calendar view.
C. Patient dashboard.
D. Patient search.

7. The office manager reviews the staff _______ periodically to determine if any unauthorized information was accessed.

A. audit trail
B. authorization checks
C. audit check
D. user name verification

8. Which one of the following conditions is considered to be an acute condition?

A. Sinusitis
B. Asthma
C. Heart disease
D. Multiple sclerosis

9. Which of the following is not a way to avoid duplicate charts?

A. Ask whether patients have been seen at the practice before.
B. Set up the patient record using the name listed on the insurance card.
C. Ask an established patient if his or her name has changed.
D. Create a new record for patients who haven't been seen in the office for more than three years.

10. Kim has an appointment with a specialist to discuss chronic syncopal episodes. She needs a copy of her PMH to be sent to the specialist. What does Kim have to provide?

A. Authorization
B. Authentication
C. Consent
D. Contract

11. A doctor prescribes a patient an antibiotic for a UTI. The prescription is sent directly to the patient's pharmacy. The pharmacist notices the patient is allergic to this medication and informs the doctor. This is an example of which core function?

A. Administrative processes
B. Orders management
C. Patient support
D. Health information management

12. In SimChart for the Medical Office, when the user selects the Clinical Care module, they will be prompted to

A. select Add a Patient.
B. perform a patient search.
C. add an appointment.
D. log out of the system.

13. Which professional organization publishes an annual EHR user satisfaction survey?

A. AAFP
B. CMS
C. AHIMA
D. AAPC

14. A diagnosis of Type 1 diabetes occurs in what part of SOAPE?

A. Subjective
B. Evaluation
C. Assessment
D. Plan

15. Weight and height are considered

A. anthropometric measurements.
B. BMI.
C. vital signs.
D. occipitofrontal circumference.

16. Guidelines for taking messages include all of the following except

A. documenting the date and time of the call.
B. documenting the initials of the person taking the message.
C. documenting the patient's name and date of birth on the message.
D. attaching the message to the patient's chart after the physician has answered the message.

17. A doctor asks a medical assistant to print a handout on hypertension for a patient to take home. This is an example of which EHR core function?

A. Administrative processes
B. Population health
C. Patient support
D. Decision support

18. What is the main reason that a physician would refer a patient to a different doctor?

A. The patient needs specialized care.
B. The patient has requested a transfer.
C. The original doctor doesn't accept the patient's insurance.
D. The doctor isn't accepting new patients.

19. _______ is a legal doctrine which holds that medical services rendered must be reasonable and necessary according to generally accepted clinical standards.

A. Medical authorization
B. Code linking
C. Medical needs
D. Medical necessity

20. How is entering a new patient in SimChart for the Medical Office performed?

A. Using the patient dashboard
B. Accessing the billing module
C. Using the Find Patient link
D. Searching the patient demographics