WorksheetsCEHRS Practice Test 3
Total questions: 82
Worksheet time: 46mins
An EHR specialist is assisting a provider with entering a patient's admission data into the health record, in which of the following areas of the EHR should the specialist document the patient's blood pressure?
Problem list
Diagnoses list
Physical examination
History of present illness
An EHR specialist works in a clinic that uses patient-entered data collection. Which of the following information should the patient enter into the EHR prior to arrival for the visit with the provider?
Recent prescription refill and pharmacy location
Date of last office visit and chief complaint
Current result of MRI procedure
History of present illness
An EHR specialist is preparing to perform a statistical review of infection rates at a facility for quality improvement purposes to compare statistical data with other facilities. The EHR system should be integrated with which of the following?
Master Patient Index (MPI)
Clinical Decision Support System (CDSS)
Uniform Ambulatory Care Set (UACS)
Clinical Encoder
An EHR specialist is performing an internal audit of the EHR records and discovers improper billing documentation that suggests potential fraud or abuse in accounts for patients with a private third-party payer. Which of the following agencies should handle this type of inquiry?
Centers for Medicare and Medicaid Services (CMS)
Office of the National Coordinator for Health Information Technology (ONC)
Office of Inspector General (OIG)
The Joint Commission (TJC)
An EHR specialist is speaking with clinical staff who are concerned about a limited number of computer workstations, resulting in delays in data entry. Which of the following suggestions should the EHR specialist make?
Defer data entry until access can be gained.
Prompt data entry is essential to patient safety and continuity of care.
Request funding for an increased number of workstations.
Reserve workstations for high-priority data.
Access the EHR through mobile devices.
An EHR specialist is assisting a medical assistant with entering a patient's ongoing temperature measurements into the EHR. The EHR specialist should understand that the result is documented in which of the following locations?
Review of systems
Flow sheet
Progress note
Encounter form
Which of the following methods should EHR specialist use to make changes or corrections to entries in the EHR?
Write an addendum to the existing entry.
Delete the original entry and insert a new entry.
Reopen the encounter and change the original entry.
Contact the health information management team to request access for a correction.
An EHR specialist is collaborating with a certified coder to create a report needed for evaluation of quality of care for hip arthroplasty surgeries done in the inpatient facility in the past year. The EHR specialist should recognize that which of the following types of codes should be used for this report?
ICD-10-CM
ICD-10-PCS
DSM-5
HCPCS
Which of the following security management processes is performed first to cover PHI?
Sanction policy
Risk management
Risk analysis
Information system activity review
When can the EHR specialist's administrative staff begin the process of verifying insurance eligibility for a new patient? When the EHR specialist receives a referral for services in the EHR?
When the patient checks in for the appointment
When the patient has received explanation of benefits from the carrier
When the patient checks out after the appointment
During preregistration
Which of the following statements by EHR support staff about the use of templates for provider documentation is correct?
Templates add desired subject of clinical to the provider documentation with one click.
Multiple templates can be used in single encounter.
Templates can be customized to work with each provider's workflow.
Lists can be both merged into encounter note but templates cannot. Templates used to structure note itself.
Which of the following patient identifiers should the EHR specialist verify before documentation is entered into EHR?
Patient's room number
Patient's provider name
Patient's medical diagnosis
Patient's medical record number
An EHR specialist is assisting a facility in implementing a recent upgrade to the EHR system. Which of the following would be the best question for the EHR specialist to ask in preparation for implementation?
How many other facilities have completed the upgrade?
What is the timeline for these changes?
What is the facility's cost for the upgrade?
What are the anticipated IT challenges of the upgrade?
An EHR specialist in a pediatrician's office to create a schedule limits contact sick children healthy. Scheduling well-child visits in the morning is working visits in the afternoon. Which of the following methods of scheduling is the EHR specialist using?
Open hours scheduling
Wave scheduling
Cluster scheduling
Modified wave scheduling
Which of the following information must be recorded in guarantor section of registration form if patient's spouse is the guarantor on?
Patient's name, date of birth, and phone number
Spouse's name, address, phone number
Address and phone number of the insurance company
A provider orders a laboratory test in the EHR. Which of the following describes the way specimens are labeled and tracked?
Specimens are delivered to the laboratory, where the labels will be generated when the laboratory personnel change the status
The specimens are not labeled in the laboratory. Unique number labels with the patient's identifying information automatically populated are printed as part of the requisition process.
The phlebotomist writes unique patient identifiers on the specimen container immediately after specimen collection
Labels with the patient's identifying information automatically populated are printed as part of the requisition process prior to specimen collection. This eliminates the potential for errors or misidentification.
Assigning collection numbers to samples according to the time they are obtained
The EHR specialist is contacted by emergency agency in another state and established patient who receiving treatment. Which network connections should the EHR specialist use to transmit information?
Local area network (LAN)
Wide area network (WAN)
Virtual private network (VPN)
Wireless fidelity (Wi-Fi)
Which of the following functions of the EHR allows query health care providers for clarification during a patient's imp?
Worklist reports
Concurrent coding
Problem list
Care plan
An EHR specialist is registering a new patient. Which of the following documents should the EHR specialist ensure is signed by the patient about why protected health information (PHI) may be released?
Advance Beneficiary Notice (ABN)
Assignment of Benefits
Notice of Privacy Practices (NPP)
General Consent for Treatment
Which of the following is an administrative safeguard used to ensure the security of electronic medical records?
Data backup and storage
Encryption
Password management
Automatic logoff
An EHR specialist is developing a template to create authorizations for the health clinic to send immunization records for college-bound patients to their respective universities. To remain compliant with the Privacy Rule, the EHR specialist should understand that which of the following items is required to be on the template?
Date signed
Time signed
Date of birth
Clinic address
An EHR specialist is training clinical coders about how to use a new clinical encoder software program. Which of the following should the EHR specialist include as a benefit of the clinical encoder program?
Replaces the code books
Helps coding professionals navigate coding pathways
Automates the entire coding process
Eliminates coding errors
An EHR specialist should identify that which of the following is the process for converting text into code for secure transmission?
Entity authentication
Data backup plan
Encryption
Integrity controls
An EHR specialist is assisting the billing department and researching a claim for a patient who has Medicare and had a procedure that was not covered by the plan. Which of the following should the EHR specialist verify was completed prior to billing the patient?
Patient day sheet
Remittance advice report
Advanced beneficiary notice
Explanation of benefits form
An EHR specialist is collaborating with a clinical coder to train the billing staff of a facility using a new EHR system that includes computer-assisted coding (CAC) software. Which of the following actions should the billers take when creating a claim to ensure the CAC assigned an accurate procedure code in the patient record?
Confirm the code with the department that performed the procedure
Validate the procedure code with documentation in the patient health record
Request an internal coding audit be performed on the procedure code
Send a query to the provider to confirm the procedure is coded correctly
An EHR specialist is educating a newly hired staff member about the security management process. Which of the following procedures should the EHR specialist indicate involves regularly reviewing records, access reports, and security incident tracking reports?
Sanction policy
Information system activity review
In which of the following sections should an EHR specialist locate objective findings from a patient's previous visit?
Past medical history
Social history
Chief complaint
Review of systems
Which of the following describes the process of claim scrubbing?
Adjusting billing to account for costs in specific geographic areas
Accepting electronic claims from providers
Categorizing services as medical, surgical, or nonsurgical
Checking the claims for any errors
An EHR specialist is providing a patient with information about the patient portal. Which of the following statements by the patient indicates an understanding of the patient portal?
I can access my medical records without the use of a username or password.
I can communicate with other patients.
I can schedule my own appointments.
I can update my preferred care plan.
An EHR specialist is assisting with providing user training to staff members regarding an upgrade to the EHR system. Which of the following statements should the EHR specialist make when asked about a way to help minimize the number of patients who miss their scheduled appointments?
The patient should be billed for any missed appointments.
The system will automatically reschedule the missed appointment.
You should send the patient a text message reminder of the appointment.
An automated confirmation of appointments may be set in the EHR system.
An EHR's software reflects a change in a patient's baseline platelet count. Which of the following methods of notification does the software use to inform the provider?
An automatic alert message
An email
A flag in the patient's record
A phone call
An EHR specialist is assisting with check-out of a patient. The patient says, "I hope I can remember everything about this new medication." Which of the following responses should the EHR specialist make?
Before you leave, let me show you where to find this medication education on the patient portal.
There is lots of medical information that you can access in the patient portal.
The new medication has few side effects.
If you have concerns about the medication, I am sure there is information about it on the Internet.
An EHR specialist should identify that which of the following members of the health care team can be granted remote access to EHRs?
Provider
Phlebotomy technician
Medical assistant
EKG technician
Which of the following is required when health care facilities provide data on vaccinations to public health agencies?
The data must refer to adult patients
The data must be from patients who have multiple conditions
The data must be dated and updated monthly
The data must be anonymous and confidential
An EHR specialist is documenting clinical data for a patient who was recently seen in an urgent care facility following a leg injury. In which of the following locations should the EHR specialist document this information?
Clinical plan
Patient's current medications
Clinical flow sheet
Problem list
When generating admission documentation for a patient, which of the following information should an EHR specialist enter in the legal data section of the EHR?
List of medications
Insurance provider
Emergency contact
Advance directives
An EHR specialist is teaching a patient about the patient portal. Which of the following statements should the specialist make?
You can update your insurance information.
You can update your employer information.
You have the ability to contact a doctor immediately in the case of an emergency.
You have access to view prescriptions and over-the-counter medications you are currently taking.
An EHR specialist is assisting with obtaining the history of a patient. The EHR specialist should document which of the following information in the history section of a progress note?
Temperature
Medication list
Cognitive status
Review of systems
An EHR specialist is assisting a registered nurse with discharging a patient who has difficulty adhering to the medication regimen. Which of the following statements should the EHR specialist make about accessing disease-specific education materials?
Our EHR system sends out general health tips. May I have your mobile telephone number?
The patient portal has lots of helpful information. I will show you how to access information about your medication.
Be sure to review your clinical summary. You should receive it in a few days.
There are many helpful websites about medication. When you search, be sure to look for sites that are reputable.
Which of the following patient laboratory findings should be automatically forwarded to the state public health agency?
Iron-deficiency anemia
Saliva sample positive for measles
Positive urine drug screen for a pregnant patient
Blood test indicating kidney failure
When preparing to enter information into a patient's record. The EHR has confirmed the patient's medical record number. Which of the following patient identifiers should the EHR use as a second identifier to the patient's identity?
Mother's maiden name
Patient's address
Patient's nearest relative, or next of kin
An EHR specialist is updating patient information in the electronic health record (EHR). Which of the following is an example of administrative data that can be found in the EHR?
Imaging test results
Demographic information
Surgical reports
Vaccination records
Which of the following is an example of a data backup method that is HIPAA compliant and allows for the recovery of data following a natural disaster?
Storing on an unencrypted thumb drive
Maintaining servers that are off site in a different region
Emailing to a personal email account
Backups that are 25 miles from the office and stored offsite
A patient presents to the emergency department and states, "I have terrible chest pain." An EHR specialist should document this information in which section of the EHR?
Past/family/social history
Chief complaint
Review of systems
Physical examination
An EHR specialist is preparing to obtain information about patient outcomes by individual provider for quality improvement. Which of the following actions should the EHR specialist take to collect the necessary information?
Contact The Joint Commission (TJC) to access the patient data for individual providers.
Generate electronic clinical reports using patient records from the EHR.
Request information from the National Quality Measures Clearinghouse (NQMC).
Meet with individual providers within the practice to obtain patient data.
Which of the following is considered protected health information?
The patient's place of birth
The patient's ZIP code
The patient's diagnosis
The patient's age
An EHR specialist receives a phone call from an established patient who has multiple chronic conditions. The patient thinks they might have pneumonia and would like to know if it would affect any of their chronic conditions. In which of the following sections of the patient's record would the chronic conditions be located?
Chief complaint
Problem list
Social history
Which of the following patient portal features meet the criteria for patient engagement as part of EHR Incentive programs?
Request my appointment
Review medical history
Send clinical summaries
Get medical advice
An EHR specialist reads a provider progress note stating, "Patient diagnosis: Lymphoma. Received six rounds of chemotherapy beginning June 2020. Patient reported diarrhea, loss of appetite, and fatigue with treatment. Last cycle of chemo was administered Nov. 2019; now in remission." Which of the following actions should the EHR specialist take?
Query the provider to resolve the discrepancy.
Input the note on the physical examination form.
Contact the patient to verify dates of treatment.
Correct the dates of treatment in the patient's record.
An EHR specialist is instructing the parent of a pediatric patient about the patient education feature in the patient portal. The parent asks, "How do I send this information to my child's step-parent?" Which of the following actions should the EHR specialist take?
Which of the following statements made by an EHR specialist describes a function of the EHR system?
It allows patients to do all their testing at home with connected devices.
It represents a short-term record of care.
It prevents syncing with a mobile device.
It streamlines the clinician's workflow.
An EHR specialist is assisting a clinic nurse with data entry related to a well-baby check-up. When entering the infant's weight into the record, the EHR specialist should understand that the data would result in which of the following types of documentation?
Assessment
Growth chart
Superbill
Review of systems
An EHR specialist is discussing hardware costs with the department controller. Which of the following statements by the department controller describes the advantage of purchasing server hardware for a local area network (LAN)?
Dedicated servers for a LAN will minimize hardware costs.
Purchasing dedicated servers for a LAN will not reduce hardware costs.
Which of the following occurs when a provider enters an Imaging order while documenting in an encounter note?
The encounter note will become part of the imaging order.
The encounter note is from the order and does not become part of the order.
Entries in the encounter note will be added to the radiologist's interpretation of the study.
The order is automatically documented in the visit.
An EHR specialist is reviewing the chart of a patient who is listed as self-pay. Which of the following notes in the chart would indicate to the EHR specialist that the client has Medicare coverage?
The patient is receiving renal dialysis for end-stage renal disease.
The patient has had a coronary artery stent.
The patient is a federal employee.
The patient's income is 150% of the federal poverty level.
An EHR specialist is assisting with training on the use of the health system's EHR. A provider asks how to correct deficiencies in their documentation. Which of the following statements should the EHR specialist make?
Records are reviewed for completeness by the provider before they are closed during an encounter.
This is a good practice but does not complete the workflow for reviewing records.
An EHR specialist receives a call from the parent of an 18-year-old patient asking why their child was seen at the office last week. Which of the following actions should the EHR specialist take?
Ask for the patient's name and date of birth and give the requested information.
Check the patient's medical record for a release of information form to determine if the parent is listed.
Notify the patient's provider to get permission to give the requested information to the parent.
Suggest the parent attend the patient's next scheduled visit in 2 weeks and ask any questions at that time.
Which of the following information is required from a prescribing provider to complete an electronic laboratory order?
Medical history
Diagnosis code
Patient's weight
Patient's allergies
An EHR specialist is accessing the EHR through a computer workstation. Which of the following are required components of a computer workstation?
A. A computer, an input device, and an output device
B. A computer tower, a monitor, and a telephone
C. Electronic equipment, a chair, and telemonitors
D. A mobile device, charging hardware, and an internet modem
When obtaining data from a new clinic patient, an EHR specialist should understand that which of the following statements by the patient indicates a history of present illness?
I had an appendectomy when I was 30.
My partner had pneumonia a year ago.
I really think I need to have a chest x-ray taken.
I came because I've been coughing for several days.
An EHR specialist is reviewing the outstanding patient account balances that were submitted to a collection agency. Which of the following documents is required to verify that the correct accounts were submitted?
Deposit report
Payment day sheet
Patient ledger
Patient aging report
An EHR specialist should look in which of the following sections to find a patient's most recent weight measurement?
Vital Signs
Medication List
Allergies
Family History
An EHR specialist is collaborating with a certified coder in a training session for outpatient billers after getting a new EHR system. Which of the following statements about the ICD-10-CM codes should the EHR specialist make?
The ICD-10-CM code needs to accurately reflect the procedure provided.
The ICD-10-CM code needs to be as shortened as possible.
The ICD-10-CM code needs to be based on the MS-DRG.
The ICD-10-CM code needs to be as specific as possible.
An EHR specialist is assisting a nurse practitioner with an electronic order entry for a patient test. Which of the following statements should the EHR specialist make?
The provider is unable to order a test while creating an encounter note.
The order system is unable to display a patient's list of recent test orders.
The order system matches order test codes with patient insurance coverage rules.
After you order the test, make sure to complete the requisition form.
An EHR specialist is assisting with the training of a newly-hired billing specialist who asks, "What is the purpose of a billing and payment status report?" Which of the following responses should the EHR specialist make?
It assists with budgeting and revenue management.
It assists with tracking payments and outstanding balances.
It assists with scheduling patient appointments.
It assists with coding accuracy.
Which of the following actions should a facility take to ensure security compliance and protect EHRs from unauthorized access?
Issue unique user identifications for use of computers.
Disable automatic logoff from computers during working hours.
Allow staff to use file-sharing applications on their mobile devices.
Deactivate remote data wiping on mobile devices.
An EHR specialist is preparing to create a report that lists patients who have received a positive result on their testicular cancer screening. Which type of production report should the EHR specialist create?
By diagnosis
By sex
By symptom
By provider
Which of the following documents is received by the health care organization from the insurance carrier after a claim has been processed?
Remittance advice
Patient consent form
Medical history report
Prescription order
An EHR specialist is assisting with providing training for a group of admission clerks about an EHR system. In which of the following data sections of the record should the EHR specialist instruct the group to enter a patient's HIPAA forms?
Clinical data
Financial data
Administrative data
Legal data
Which of the following actions should a patient take to authorize a participating health care organization to receive payment from a third-party payer?
Verbally authorize assignment of benefits to the health care organization
Provide a signature for assignment of benefits to the health care organization
Contact the third-party payer to assign benefits to the health care organization
Contact an insurance agent to assign benefits to the health care organization
A new medical group is planning to hire a privately owned Information technology (IT) company to manage its IT operations. Which of the following actions should the medical practice take to ensure the IT company will maintain the security of all data transmissions?
Obtain a copy of the IT company's procedure manual.
Confirm they are certified by the Centers for Medicare and Medicaid Services.
Review the IT company's record filed with its state regulatory agency.
Enter into a business associates contract with the IT contractors.
An EHR specialist is assisting a billing specialist with entering codes for durable medical equipment. Which of the following manuals should the EHR specialist instruct the patient billing specialist to use?
HCPCS manual
Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5)
CPT manual
An EHR specialist scans an image to a patient's medical record prior to the patient's scheduled appointment using the office scanner connected to the desktop computer by USB cable. At the appointment, the provider is unable to find the image for review. Which of the following is the likely cause?
Scanned documents are routed, in random order, to a single tab in the EHR.
There was a decryption error in document transmission.
The image was incorrectly catalogued.
It was not electronically signed by the EHR specialist.
Which of the following is the coding standard used for mapping laboratory procedures to common terminology in EHR systems?
DICOM
ICD-10-CM
LOINC
Which of the following forms is used to capture the diagnoses and charges related to a patient visit prior to submitting them for reimbursement?
CMS-1500 form
Remittance advice
Encounter form
UB-04 form
An EHR specialist is assisting a nurse who receives a prescription for morphine sulfate sent via the EHR system. The prescription states, "Increase MS to 2 mg IV Q4H." The EHR specialist should reconcile the information to read as which of the following statements in the patient's record?
In EHR medication reconciliation, prescriptions must be clarified for safety and compliance with standards like those from The Joint Commission and ISMP, which emphasize spelling out drug names (e.g., "MS" can be confused with magnesium sulfate) and routes (e.g., "IV" as "intravenously") while using precise dosing (e.g., "2.0 mg"). "Q4H" is a standard, acceptable abbreviation for "every 4 hours." Which of the following prescriptions is correct?
MS 2 mg IV every four hours.
Morphine sulfate 2 mg VQ4H.
MS 2 milligrams N Q4H.
Morphine sulfate 2 mg IV Q4H.
An EHR specialist is assisting a records clerk with the handling of a removable media device containing protected health information (PHI). Which of the following actions should the EHR specialist tell the clerk to take to prevent a security risk?
Place the device in an allocated area for reuse.
Discard the device in the front office trash bin.
Remove protected health information from the device.
Make a copy of the information on the device to store in an offsite location.
A medical office receives an imaging report via fax machine and an EHR specialist scans it into the patient's record. This is an example of which of the following methods of data collection?
Manual
Interfacing
Automated
Interoperable
Which of the following types of data are considered structured data in the EHR?
ICD codes
Progress notes
An EHR specialist is preparing to generate a report for a supervisor that indicates the amount of revenue generated by throat cultures. Which of the following reports should the EHR specialist generate?
Day sheet report
Remittance advice report
Billing/payment status report
Production by procedure report
An EHR specialist is collaborating with a coder about reports available in the new EHR system. The EHR specialist should instruct the coder that which of the following reports shows the income generated by each third-party payer?
Day sheet report
Patient aging report
Production by insurance report
