Test Bank for The Electronic Health Record for the Physician’s Office For Simchart for the Medical Office, 2nd Edition, Julie Pepper.pdf

Test Bank for The Electronic Health Record for the Physician’s Office For Simchart for the Medical Office, 2nd Edition, Julie P Chapter 01: Introduction to Electronic Health Records Test Bank MULTIPLE CHOICE 1. A physical collection of an individual’s healthcare information is termed: a. patient chart. b. patient record. c. electronic health record. d. EMR. e. All of the above ANS: E All of the above are collections of an individual patient’s health data. REF: p. 2|p. 8 OBJ: 1 2. Early medical documentation of present day post-traumatic stress syndrome was first seen in: a. the U.S. Civil War. b. the plagues of Europe. c. 200 BC China. d. the Korean War. e. WWII. ANS: A Post-traumatic stress syndrome was first documented as “nervous disease” during the U.S. Civil War. REF: p. 2 OBJ: 1 3. Which of the following is NOT found in the patient medical record? a. Immunization records b. Operative reports c. Living will d. Patient statement e. Referral letters ANS: D Immunization records, operative reports, living wills, and referral letters are all common contents of the patient record. REF: p. 3 OBJ: 2 4. An example of a HIPAA form that is included in the medical record would be: a. a patient information sheet. b. a living will. c. a Notice of Privacy Practices acknowledgement. d. informed consent forms. e. H&P. ANS: C HIPAA requires that all patients be provided with the Notice of Privacy Practices and that the provider document that the patient has received the notice. That acknowledgement must be included in the medical record. REF: p. 4 OBJ: 2 5. An individual who is responsible for recording data in the patient record is called a: a. transcriber. b. health records clerk. c. data entry clerk. d. documenter. e. guarantor. ANS: D Documenter is the term given to an individual who places information into the patient chart. REF: p. 4 OBJ: 3