Electronic Medical
Records Final Exam Study
Guide with Correct
Solutions
Jesse Lopez is a healthcare professional at Summit Bay Health Center. He has just
finished submitting claims to Blue Shield for patients seen yesterday. Jesse was
performing what type of function? - ANSWER-Administrative
Of the following, which does not need to be sent to an insurance company of the CMS-
1500 claim form? - ANSWER-History of present illness
Roberta is a healthcare professional at Dr. Ingram's office. She has a patient on the
phone who wants to make an appointment with Dr. Ingram. What will Roberta first take
into consideration when looking for an open appointment time? - ANSWER-The reason
for the patient's visit
Which of the following is not a type of medical insurance? - ANSWER-Self-pay from
patient
Dr. Evans' office has computerized the following functions: appointment scheduling,
charge capture, collections, and reporting. These are all found in which type of
software? - ANSWER-Practice management
You are a registrar in the admitting office of a hospital; a patient presents to register for
an outpatient laboratory test. What will you first access to determine if that patient has
ever been seen at that hospital before, or whether you must register him for the first
time? - ANSWER-Master Patient (Person) Index
EHRclinic uses a single _________________ to store administrative and clinical data
on each patient. - ANSWER-Database
Of the following, which contributes to the high cost of electronic health records for the
software service provider? - ANSWER-Research and development costs
Which of the following statements is accurately describes duplicate patient registration
and electronic health record system? - ANSWER-Duplicate patient registrations can
,occur if the patient's name was misspelled of the patient was previously registered
under a different name.
Research has shown what in relation to the use of an EHR? - ANSWER-There has
been a decrease in medical errors through the use of EHR software.
Which of the following EHR applications may be more beneficial and efficient for the
patient? - ANSWER-ePrescribing
Though the costs of implementation will be high, which record-keeping costs will
ultimately drop as a result of implementing an electronic health record? - ANSWER-
Costs of folders and clips to file each record
During the history of present illness, the healthcare professional asks Ron Albertson for
his preferred pharmacy. The healthcare professional then enters the information into
EHRclinic. After the care provider has examined and diagnosed Mr. Albertson, he
prescribes Amoxicillin and electronically sends the prescription to Mr. Albertson's
chosen pharmacy without having to enter any additional information into the ePrescribe
module. This is an example of - ANSWER-Interoperability
Of the following, which is not an application of an EHR system? - ANSWER-Capture of
insurance policy number
In a physician's practice, the documentation of a patient's office visit is often referred to
as a - ANSWER-Progress note
A care provider is dictating a progress note into speech recognition while the patient is
being seen. This dictation is occurring - ANSWER-at the point of care
Of the following, which is not clinical information? - ANSWER-age
You are a healthcare professional at Summit Bay Health Center and you have just
shown a patient, Mrs. Clark, to the check-out desk, where the billing coordinator had
just taken the encounter form (superbill) for the visit. Dr. Daniels came to the window
and stated that Mrs. Clark left the exam room before receiving her flu shot. What will
occur in this case? - ANSWER-Mrs. Clark will be taken back to the exam room; she will
be given the injection by the healthcare professional, who will document it in Mrs.
Clark's record and will then update the encounter form to reflect the charges for the flu
shot; at that point, Mrs. Clark will return to the check-out desk.
Which of the following is not a care provider? - ANSWER-Medical Assistant
Christine Simmons arrived for her appointment with Dr. Shumaker 20 minutes ago. The
healthcare professional has just left the room after taking Christine's vital signs, weight,
and a brief history of present illness. What will be the next step in Christine's flow
through the overall process? - ANSWER-The care provider will see the patient
, The first step of the information chain in an electronic system is - ANSWER-patient
makes the appointment
The steps listed below are carried out by which staff during an office visit?
Patient arrives for visit → Update patient information → Check in and collect co-pay →
Start patient tracking - ANSWER-registration/front-desk staff
Which of the following functions is carried out during the check-in steps? - ANSWER-
Healthcare professional updates patient information
The feature in EHRclinic that guides the user on how specific functions or applications
work is known as - ANSWER-Help
Sean Brown is a new care provider and has never before used EHRclinic. He is
frustrated, and though you have been trying to help him, he is still having difficulty. What
would be sound advice to give to Dr. Brown? - ANSWER-Direct him to the User's Guide
in EHRclinic and show him the index, contents, and search features
Which of the following is not a professional organization related to the fields of health
information, medical assisting, or allied health? - ANSWER-American Hospital
Association
The health information manager and the ___________________ work closely to ensure
a fully operational, secure electronic health record that meets the needs of all users
within the facility? - ANSWER-Information Technology Manage/Officer
A ______________________ professional would most likely hold one of the following
positions: cancer registrar, privacy officer, software analyst, or compliance officer. -
ANSWER-Registered Health Information Administrator (RHIA)
In a hospital setting, the management personnel and much of the staff of the
department responsible for maintaining and retrieving data from health records are often
certified through and members of which professional organization? - ANSWER-
American Health Information Management Association (AHIMA)
The staff of the ___________________ will need to enter, maintain, and retrieve data
from electronic health records within a hospital setting. - ANSWER-Health information
department
The progress note of Amy Shaw states that she is a 51-year-old female who has a
history of lower back pain following a fall off a ladder in 2007. She has been taking
ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs
to miss work. Based on her history and the results of the physician's physical exam, his
treatment plan is naproxen sodium daily and an order for physical therapy to include
Records Final Exam Study
Guide with Correct
Solutions
Jesse Lopez is a healthcare professional at Summit Bay Health Center. He has just
finished submitting claims to Blue Shield for patients seen yesterday. Jesse was
performing what type of function? - ANSWER-Administrative
Of the following, which does not need to be sent to an insurance company of the CMS-
1500 claim form? - ANSWER-History of present illness
Roberta is a healthcare professional at Dr. Ingram's office. She has a patient on the
phone who wants to make an appointment with Dr. Ingram. What will Roberta first take
into consideration when looking for an open appointment time? - ANSWER-The reason
for the patient's visit
Which of the following is not a type of medical insurance? - ANSWER-Self-pay from
patient
Dr. Evans' office has computerized the following functions: appointment scheduling,
charge capture, collections, and reporting. These are all found in which type of
software? - ANSWER-Practice management
You are a registrar in the admitting office of a hospital; a patient presents to register for
an outpatient laboratory test. What will you first access to determine if that patient has
ever been seen at that hospital before, or whether you must register him for the first
time? - ANSWER-Master Patient (Person) Index
EHRclinic uses a single _________________ to store administrative and clinical data
on each patient. - ANSWER-Database
Of the following, which contributes to the high cost of electronic health records for the
software service provider? - ANSWER-Research and development costs
Which of the following statements is accurately describes duplicate patient registration
and electronic health record system? - ANSWER-Duplicate patient registrations can
,occur if the patient's name was misspelled of the patient was previously registered
under a different name.
Research has shown what in relation to the use of an EHR? - ANSWER-There has
been a decrease in medical errors through the use of EHR software.
Which of the following EHR applications may be more beneficial and efficient for the
patient? - ANSWER-ePrescribing
Though the costs of implementation will be high, which record-keeping costs will
ultimately drop as a result of implementing an electronic health record? - ANSWER-
Costs of folders and clips to file each record
During the history of present illness, the healthcare professional asks Ron Albertson for
his preferred pharmacy. The healthcare professional then enters the information into
EHRclinic. After the care provider has examined and diagnosed Mr. Albertson, he
prescribes Amoxicillin and electronically sends the prescription to Mr. Albertson's
chosen pharmacy without having to enter any additional information into the ePrescribe
module. This is an example of - ANSWER-Interoperability
Of the following, which is not an application of an EHR system? - ANSWER-Capture of
insurance policy number
In a physician's practice, the documentation of a patient's office visit is often referred to
as a - ANSWER-Progress note
A care provider is dictating a progress note into speech recognition while the patient is
being seen. This dictation is occurring - ANSWER-at the point of care
Of the following, which is not clinical information? - ANSWER-age
You are a healthcare professional at Summit Bay Health Center and you have just
shown a patient, Mrs. Clark, to the check-out desk, where the billing coordinator had
just taken the encounter form (superbill) for the visit. Dr. Daniels came to the window
and stated that Mrs. Clark left the exam room before receiving her flu shot. What will
occur in this case? - ANSWER-Mrs. Clark will be taken back to the exam room; she will
be given the injection by the healthcare professional, who will document it in Mrs.
Clark's record and will then update the encounter form to reflect the charges for the flu
shot; at that point, Mrs. Clark will return to the check-out desk.
Which of the following is not a care provider? - ANSWER-Medical Assistant
Christine Simmons arrived for her appointment with Dr. Shumaker 20 minutes ago. The
healthcare professional has just left the room after taking Christine's vital signs, weight,
and a brief history of present illness. What will be the next step in Christine's flow
through the overall process? - ANSWER-The care provider will see the patient
, The first step of the information chain in an electronic system is - ANSWER-patient
makes the appointment
The steps listed below are carried out by which staff during an office visit?
Patient arrives for visit → Update patient information → Check in and collect co-pay →
Start patient tracking - ANSWER-registration/front-desk staff
Which of the following functions is carried out during the check-in steps? - ANSWER-
Healthcare professional updates patient information
The feature in EHRclinic that guides the user on how specific functions or applications
work is known as - ANSWER-Help
Sean Brown is a new care provider and has never before used EHRclinic. He is
frustrated, and though you have been trying to help him, he is still having difficulty. What
would be sound advice to give to Dr. Brown? - ANSWER-Direct him to the User's Guide
in EHRclinic and show him the index, contents, and search features
Which of the following is not a professional organization related to the fields of health
information, medical assisting, or allied health? - ANSWER-American Hospital
Association
The health information manager and the ___________________ work closely to ensure
a fully operational, secure electronic health record that meets the needs of all users
within the facility? - ANSWER-Information Technology Manage/Officer
A ______________________ professional would most likely hold one of the following
positions: cancer registrar, privacy officer, software analyst, or compliance officer. -
ANSWER-Registered Health Information Administrator (RHIA)
In a hospital setting, the management personnel and much of the staff of the
department responsible for maintaining and retrieving data from health records are often
certified through and members of which professional organization? - ANSWER-
American Health Information Management Association (AHIMA)
The staff of the ___________________ will need to enter, maintain, and retrieve data
from electronic health records within a hospital setting. - ANSWER-Health information
department
The progress note of Amy Shaw states that she is a 51-year-old female who has a
history of lower back pain following a fall off a ladder in 2007. She has been taking
ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs
to miss work. Based on her history and the results of the physician's physical exam, his
treatment plan is naproxen sodium daily and an order for physical therapy to include
