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WorksheetsCEHRS Quiz 2
Total questions: 20
Worksheet time: 13mins
Which of the following medical record review findings indicates upcoding of clinical documentation in the EHR?
Using a CPT code that yields a higher reimbursement than what was documented
Using a CPT code that yields a lower reimbursement than what was documented
Assigning a CPT code for a service that was performed as scheduled
Using an automatically assigned code
Which of the following components of a Subjective, Objective, Assessment, Plan (SOAP) note would pull in real-time test results from the EHR?
Subjective
Objective
Assessment
Plan
An EHR specialist is speaking with a patient who states, "I don't know where to access education materials about my disease." Which of the following responses should the EHR specialist make?
You should use social media to learn more about your disease.
You can access patient education materials using the patient portal.
You should try not to think too much about your disease.
You can ask your provider more questions at your next visit.
An EHR specialist in a clinic is assisting a patient with documenting past medical, social, and family history. The patient completing the electronic questionnaire asks, "Where do I include drug use?" The EHR specialist should reply that drug use should be documented in which of the following social history components?
Alcohol use
Tobacco use
Caffeine use
Recreational use
Which of the following public health objectives involves securely transferring data and information related to cases of measles to public health agencies (PHAs)?
Trauma registries
Syndromic surveillance
Immunization registries
Reportable laboratory results
Which of the following forms of data capture should be identified as demographic information?
Vital signs
Chief complaint
Marital status
A nurse asks an EHR specialist for help to locate the education sheets for smoking cessation in the EHR. Which of the following patient education forms should the EHR specialist suggest?
American Heart Association (AHA): What is Hypotension?
Centers for Disease Control and Prevention (CDC): COPD Are You at Risk?
Centers for Disease Control and Prevention (CDC): Diabetes Are You at Risk?
National Institutes of Health (NIH): Pulmonary Embolism Information
Which of the following coding techniques allows an EHR specialist to review clinical documentation while the patient is actively receiving treatment?
Upcoding
Computer-assisted coding
Concurrent coding
Undercoding
An EHR specialist is providing support for computerized provider order entry (CPOE). A provider asks, "Where should I document my treatment instructions and ordered tests?" Which of the following statements should the EHR specialist make?
This can be documented in the subjective details portion of the SOAP note.
This can be documented in the objective details portion of the SOAP note.
This can be documented in the plan details portion of the SOAP note.
Which of the following automatically assigns the appropriate diagnosis and procedure codes based on clinical documentation in the EHR?
Computer-assisted coding
Superbill
Upcoding
Physician query
In which of the following history sections of the EHR would a patient's history of alcohol use be documented?
Medical
Surgical
Family
Social
Which of the following types of clinical data can be ordered during a patient visit in the computerized provider order entry (CPOE) workflow?
Laboratory testing
Medication administration
Patient demographics
Insurance information
A compliance director asks an EHR specialist to verify that a patient has received information on privacy practices. To which of the following form should the EHR specialist navigate in the EHR?
HIPAA consent form
Release of records
Advance directives
Informed consent
Which of the following sections of the EHR should an EHR specialist review to obtain a patient's Influenza vaccine status?
Allergies
Immunizations
Preventive care
Medical history
An EHR specialist is assisting a provider with navigating the EHR system to accept a patient from one health care provider to another. Under which of the following types of permitted disclosures is the provider retrieving the patient data?
Payment
Treatment
When reviewing history and physical templates, the review of systems includes which of the following components?
Medical examination
Medication status
Constitutional symptoms
Tobacco use
An EHR specialist is preparing to share a secure spreadsheet containing patient heart information from a Holter monitoring device with the provider. Which of the following actions should the EHR specialist take to protect the information?
Share the spreadsheet password with the provider.
Send the spreadsheet without a password.
Send the spreadsheet to the provider's personal email address.
Use a public Internet connection to transmit the spreadsheet.
Which of the following actions would generate a real-time alert message in the EHR?
An EHR specialist is providing support for a provider who is entering prescriptions into a patient's chart using a new EHR system. The provider asks the EHR specialist which pharmacy will automatically receive the prescription. Which of the following responses should the EHR specialist make?
The pharmacy closest to the patient's address.
The pharmacy closest to our office's location.
The patient can walk into any pharmacy to fill the e-prescription.
The patient's preferred pharmacy must be entered.
An EHR specialist is training providers on required clinical documentation in the hospital setting. A provider asks, "How can I make sure to include all relevant data elements?" Which of the following statements should the EHR specialist make?
Use a cloned progress note.
Use a specialized note with negative prompts.
Use a progress note template.
Use a personal note template.
