EHR STUDY GUIDE

Which of the following is a primary duty of an EHR specialist as the health care industry implements EHR requirements?

Providing ongoing training of EHR software.

An insurance adjustor requests a patient's progress notes following a motor vehicle crash. Which of the following should guide the EHR specialist in releasing this information?

Minimum Necessary

Which of the following is a feature of clinical decision support?

Allows patient care to be tailored to published guidelines

A patient smokes four packs of cigarettes per day and has chronic obstructive pulmonary disease (COPD). The patient presents for an office visit for a urinary tract infection. Which of the following is the primary diagnosis for this visit?

Urinary tract Infection

Which of the following eliminates errors that arise from illegible handwriting and provides safety checks?

E-prescribing

A patient presents to a provider's office with strep throat. In which of the following locations of EHR would information about the onset and duration of the symptoms be documented?

History of present illness (HPI)

A government research study has requested patient data. Which of the following actions should an EHR specialist take after confirming correct authorization?

Remove PHI from the data

Which of the following circumstances requires a patient to give specific authorization for the release of PHI?

Mental health treatment

A provider performs a chest x-ray before and after the placement of a chest tube. This repeat procedure by the same provider should be coded with which of the following?

Modifier

Which of the following is the most important reason to maintain an inventory of software used in an office?

To deter unauthorized duplication

A patient presents to a provider's office with a third degree burn on his hand from cooking oil. Which of the following should an EHR specialist code first?

Classification

The scheduling template within an EHR system can be used for which of the following?

Identifying a lack of resources that interferes with workflow

Which of the following is the process of converting electronic information into an unreadable format before it is distributed?

Encryption

Billed procedures and services should be supported by which of the following?

Medical record

An EHR specialist is posting payments for a patient whose insurance plan covers 100% of the price of an office visit with a $25 co-payment per visit after the patient meets the annual deductible of $250. To date, none of the deductible has been met. The price of an office visit is $96. Which of the following payments should be collected from the patient at the time of the office visit?

$96

Which of the following should a provider's office document to demonstrate it is HIPAA complaint?

Audit trail results

Which of the following parts of the financial information system would be used to manage aging reports by guarantor or carrier?

Claims management

Which of the following allows for entering and retrieving data, and is a special programming language for databases?

SQL

Which of the following analyzes medical codes for patient encounters and reports any errors?

Claim scrubber

Which of the following is included in an implant registry?

Manufacturer

Health Level 7 (HL7) is used for which of the following reasons?

To exchange information between systems

Which of the following describes point of care (POC) documentation?

The provider documents the information during the patient encounter.

Which of the following is a function of the Drug Utilization Review (DUR) feature in an EHR system?

To flag possible medication interactions

An EHR specialist is registering a patient. Which of the following should he include in the patient demographics?

Date of birth

An EHR-based provider's office is expanding from two employees to five. Which of the following actions is the most important to maintain security of protected health information?

Set up role-based access controls

Which of the following refers to a provider's liability for the wrongful acts of his employees?

Respondeat superior

Which of the following is an advantage of using clinical templates to record patient encounters?

Standardizes documentation formats

Which of the following actions should an EHR specialist complete before scanning a hard-copy document into an EHR system?

Verify the correct patient is selected

Which of the following should an EHR specialist retrieve from a patient's record when a provider refers the patient to a specialist?

Insurance information

Which of the following steps should an EHR specialist take when preparing a patient's information for review at an internal cancer committee meeting?

Remove the medical record number

Which of the following safeguards includes authentication controls for a patient's PHI?

Technical

Which of the following should a facility include in its disaster recovery plan?

Maintaining a list of IT infrastructure

Which of the following can be integrated with an EHR system to automatically generate ICD and CPT information directly from clinical documentation?

Computer-assisted coding

Hospital A was recognized for its employee safety record, and hospital B has set a goal to achieve similar results. This is an example of which of the following?

Benchmarking

Which of the following is a feature of a patient portal within an EHR system?

Patients can input health status updates between appointments

Which of the following is an example of a static report?

Birth register for a particular day

Twenty patients who smoke were counseled against smoking, and 15 were not. Which of the following is the ratio of patients who were counseled to those who were not?

4.3

In which of the following can be EHR specialist find documentation to verify the time of a medication administration?

MAR

Which of the following is a threat to the security of information in an EHR system?

Environmental factors

An EHR specialist wants to differentiate the health information recorded for patients who are pregnant. In which of the following ways should the EHR specialist accomplish this task?

Develop clinical templates to capture data specific to the diagnosis

In which of the following areas of a patient's EHR will the EHR specialist find the necessary documentation to substantiate a short-term disability claim for a woman on a maternity leave

Discharge summary

A provider's office is using coding software with the ability to receive updates twice per year. Which of the following codes follows this updating schedule?

ICD-10-CM

From which of the following parts of a SOAP note should an EHR specialist abstract a diagnosis?

Assessment

Which of the following is the main reason computerized physician order entry CPOE should be used?

It eliminates errors caused by transcription of handwritten or verbal orders

A mother presents insurance information for her son's office visit. He is covered by two policies. The mother carries one policy, and the father carries the other. The mother's birthday is November 4,1972 and the father's birthday is January 4, 1973. To which of the following insurance plans should an EHR specialist bill this office visit?

The father's insurance as primary and the mother's insurance as secondary

An EHR specialist is accessing her facility's provider database. Which of the following is she looking for?

Specialty referrals

An EHR specialist working the front desk at provider's office is managing an overcrowded waiting room. The EHR specialist should do which of the following when processing co-payments?

Verify each patient's co-payment amount.

Which of the following should an EHR specialist do after entering diagnosis and procedural codes in an office using an EHR system?

Submit claims for reimbursement

During an office visit, a provider examines a 9-month old patient for a diaper rash. Which of the following types of codes should the EHR specialist use to clarify this type of visit?

Evaluation and Management Services codes

A patient who has medicare coverage opts to have a procedure performed that is covered. Which of the following forms is the patient required to sign to have this non-covered procedure performed?

Advance Beneficiary Notice

An EHR specialist is abstracting information for a study regarding the sexual history of teen patients. For which of the following locations should she retrieve this information?

Social history

If a patient has insurance that requires a co-payment, which of the following is needed to accurately collect and post the patient's payment?

Encounter form

Which of the following is an example of meaningful use?

A provider electronically exchanges a patient's laboratory data with a medical specialist

A patient provides a document detailing her marital status. In which of the following sections should this information be recorded?

Social history

Which of the following gives bonuses to providers who submit their use of recognized ongoing performance measurements to Medicare?

Physician Quality Reporting System

Which of the following represents Protected Health Information (PHI)?

Patient's medical record number

Which of the following is a comprehensive clinical vocabulary designed to encompass all terms used in health care?

SNOMED-CT

Anyone who thinks a health care provider has violated HIPAA privacy regulations can file a written complaint within 180 days to which of the following organizations?

Office of Civil Rights (OCR)

Storing backup data or media in an off-site location is an example of which of the following?

Physical safeguard

Which of the following reports indicates the status of a claim since submission?

Aging report

Which of the following is the best method to ensure restoration of EHR documents?

Back up all database information

An EHR specialists submits an incorrect policy number to the insurance company. Which of the following scenarios will occur?

Payment will be denied

An EHR specialist is monitoring changes to CPT codes for his facility. these code changes are managed and updated by which of the following?

American Medical Association (AMA)

Which of the following is an automated benefit of using an EHR system at the time of service?

Providing decision support

Which of the following statements demonstrates the use of an aging report?

Health care providers must track the amounts of money due from both patients and insurance carriers

Which of the following should an EHR specialist look for as part pf a routine chart audit?

Assignment of Benefits form

Which of the following patients' rights do HIPAA regulations address?

To access personal diagnosis history

Prior to transmitting claims, an EHR specialist is reviewing provider documentation on each claim being billed to ensure all required information has been documented. Which of the following must be documented in patient chart for each encounter?

Provider signature

Which of the following computerized documents would an EHR specialist generate to obtain a patient-specific list of procedures, services, and supplies with associated costs?

Charge description master

Which of the following is the most important reason the provider should include comprehensive documentation in the patient record?

To demonstrate médica necessity that ensures correct payment to the provider

Which of the following is necessary for computer systems to exchange information?

Interoperability

A clinician is recording patient information. Which of the following information should a clinician documents as subjective?

Chief complaint

An EHR specialist enters a patient's insurance information into the EHR system. How long does it take for this information to post to the patient's chart?

As soon as the information is entered

A patient presents to a provider's office for a scheduled appointment. Before seeing his doctor, a co-payment is requested. The patient notifies the EHR specialist that he forgot his payment. Which of the following steps should the EHR specialist take?

Bill the patient

An EHR specialist receives a request from a patient for a copy of her medical record. When accessing the patient's information, the EHR specialist notices the patient has an outstanding balance. Which of the following actions should the specialist take?

Provide the patient with a copy of the record

Which of the following does the Office of Inspector General recommend as part of a facility's compliance plan?

Conduct audits of charting for billing accuracy

Which of the following is a benefit of inpatient hospital EHR systems?

Provides access to current patient information

Which of the following is the first step of the scanning process?

Document preparation

According to HIPAA, the use of CPT and ICD-10-CM code sets is required for which of the following?

Electronic Data Interchange

According to HIPAA's privacy rule, in which of the following situations is a patient required to sign an authorization to release PHI?

A School requests a pediatric patient's physical exam results for sports eligibility

According to HIPAA, which of te following is considered protected health information in a medical record?

Photographic images

Which of the following scenarios demonstrates a facility's adherence to proper training procedures regarding an EHR system?

Employees receive training when software upgrades significantly change process.

Which of the following describes the reference used to enter diagnosis codes in a hospital setting?

ICD-10-CM

For which of the following reasons should an EHR specialist run a statistical report containing information about patients' colonoscopies and fecal occult blood tests?

Performance-based pay

According to HIPAA, which of the following is a covered entity?

Clearinghouse

Proper documentation to support reimbursement of services is the responsibility of which of the following members of the health care team?

Clinician

When purging inactive health records, which of the following pieces of information must an EHR specialist retain?

Birth date

Before a surgical procedure, an EHR specialist should obtain which of the following to ensure payment of the claim by the third-party payer?

Preauthorization

Which of the following is the maximum number of days a provider's office has to notify patients when there is a breach to medical record security?

60 days

Which of the following is a benefit of documenting a patient encounter at this point of care?

Improved patient outcomes

An EHR specialist is coding for the reimbursement of durable medical equipment. Which of the following code sets should she use?

HCPCS

Which of the following is included on a face sheet?

Advance directives

A patient is being seen in a clinic for a follow-up visit. The medical assistant has gathered the patient's vital signs. In which of the following should this information be entered?

EMR

An EHR specialist is reviewing patient records to ensure charts are being properly completed. Which of the following tasks is he performing?

Auditing

An EHR specialist is coding a claim for a patient who fell off a chair and broke an arm. Which of the following is necessary to explain the patient's condition in full

V-Y codes

Which of the following federal acts mandates physical, technical, and administrative safeguards?

HIPAA Title II

Which of the following statements would be documented in the physical examination?

Negative bowel sounds

A patient is admitted with tonsillitis for which a tonsillectomy was performed. During the recovery, the patient fell and fractured the right ulna, requiring reduction of the bone. The principal procedure will be listed as

Tonsillectomy

Which of the following is the first step when processing a record request in a manual system?

Validate authorization for release

Which of the following is the coding system used to convert written diagnoses into numeric form?

ICD