ADMINISTRATIVE AND CLINICAL USE OF THE EHR

1. Plan of care, evaluation, subjective data, and objective data are all parts of

A. a telephone encounter.

B. documentation.

C. the progress note.

D. a clinic visit.

 

2. Mr. Smith has an appointment with Dr. Johnson at 9:00 A.M. for his annual wellness exam. Mrs. Adams calls the clinic first thing in the morning due to fever, chills, and cough for 3 days and is given an appointment at 9:00 A.M. with Dr. Johnson as well. This is an example of

A. overlap.

B. accommodating.

C. jamming.

D. double-booking.

 

3. A provider performs _______ to signify that everything in the note is correct.

A. technological signature

B. digital signature

C. annotation

D. autograph

 

4. Dan has made an appointment for review of his medication, as he recently relocated to the area with his family. Before his appointment, he has been asked to fill out and bring _______ form.

A. disclosure

B. health history

C. review of systems

D. consent

 

5. Incident reports are reviewed by the staff to aid in

A. policies.

B. prevention.

C. change.

D. procedures.

 

6. Which of the following is an appropriate way to reduce no-show appointments?

A. Ensure the patient writes down their appointment.

B. Perform reminder calls one to two days preceding the appointment.

C. There are no good ways to reduce no-shows.

D. Schedule all appointments within seven days of the appointment day.

 

7. A patient notes that they smoke a half a pack of cigarettes per day and drink a six pack of beer every night. Where would this be documented in the chart?

A. Medical history

B. Social history

C. Chief complaint

D. Problem list

 

8. Which of the following is not considered an integrated device?

A. Telephone

B. Signature pad

C. Scanners

D. Camera

 

9. _______ allows for disclosure of protected health information (PHI) through phone, fax, or email without specific patient authorization.

A. Confidentiality

B. HIPAA Security Rule

C. HIPAA Privacy Rule

D. Clinic policies and procedures

 

10. _______ is the most important responsibility of all members of the medical office.

A. Communication

B. Accountability

C. Documentation

D. Punctuality

 

11. All of the following require an incident report to be filed except

A. if the wrong patient is contacted for an appointment reminder.

B. if the employee suffers a needle stick.

C. if the wrong medication is administered to the patient.

D. if the patient falls in the hallway.

 

12. The process of a data code being unreadable until its destination is reach is called

A. cryptic.

B. jumble.

C. decryption.

D. encryption.

 

13. The _______ is a centralized location for a summary of a patient’s acute and chronic conditions.

A. chief complaint

B. medical history

C. disease list

D. problem list

 

14. Which of the following are not guidelines for proper telephone etiquette?

A. Answer by the third ring is possible

B. Answer with a pleasant greeting

C. Speak slowly and clearly

D. Keep a straight, professional face

 

15. Myrtle uses a cane to ambulate. She came to the clinic for an appointment, but before making it inside the building she tripped and fell on the curb. What type of document needs to be created?

A. Incident report

B. Fall report

C. Accident report

D. Injury report

 

16. Through the use of _______ a patient may view open appointments or schedule their own appointment.

A. patient access

B. patient flow

C. patient gateway

D. patient portal

 

17. Cindy has a hand-written fax number from a patient’s parent to fax a note to the school for use of a medication while at school. Cindy is unable to read all of the fax numbers. What should she do?

A. Avoid sending the note since the correct number wasn’t given

B. Call the patient to confirm the number

C. Send to the closest number

D. Ask other office staff

 

18. What’s the default landing page in SCMO when entering a patient encounter?

A. Allergies

B. Chief complaint

C. Vital signs

D. Progress note

 

19. _______ is a rundown of organ systems that can be used to pinpoint certain concerns or unusual findings.

End of exam

A. Review of systems

B. Report of symptoms

C. Report of systems

D. Review of symptoms

 

20. “It feels like an ice pick in my head” and “I’m coughing up a lung” are considered

A. chief complaints.

B. reason for visit.

C. presenting symptom.

D. medical concerns.

Describe Two External Stressors That Are Unique To Adolescents