Deck 5: Content of the Health Recordthe Care Providers Responsibility

Question 1

Which of the following is a benefit of voice recognition technology?

A) The cost is lower to implement.
B) From the beginning it is less time consuming for the care provider.
C) Documents are made part of the patient's record in a timelier manner.
D) One hundred percent accuracy is attainable.

Answer 1

Documents are made part of the patient's record in a timelier manner.

Question 2

One of the reasons ePrescribing is being used by a greater number of physicians' practices is that it

A) is required under HIPAA.
B) is a requirement of the HITECH Meaningful Use regulations.
C) is required by most commercial insurance companies.
D) is increasingly a requirement of pharmacies.

Answer 2

is a requirement of the HITECH Meaningful Use regulations.

Question 3

Which of the following is an advantage of dictation and transcription?

A) patients automatically receive copies
B) very inexpensive as compared to written notes
C) saves on paper and supplies as compared to speech recognition
D) allows for greater accuracy than written notes

Answer 3

allows for greater accuracy than written notes

Question 4

Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Philips, by typing the sentences: "The patient is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He voices no other complaints." This is an example of _________________ data.

A) structured
B) unstructured
C) quantitative
D) qualitative

Question 5

The results of a patient's rapid strep test would be found in what area of a SOAP note?

A) subjective
B) objective
C) assessment
D) plan

Question 6

During the history, Kevin Goodell notes that the pain in his right hip is more of a dull pain than an ache. This is considered what part of the history of present illness (HPI)?

A) location
B) quality
C) severity
D) modifying factor

Question 7

A patient with knee pain has been using pain patches to alleviate the pain; she has been using the kind that are left on the area for several hours. Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI).

A) location
B) timing
C) severity
D) modifying factors

Question 8

The SOAP documentation format is most commonly used in which healthcare setting?

A) hospital inpatient
B) physician's office
C) hospital emergency department
D) outpatient diagnostic department

Question 9

A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI).

A) associated signs and symptoms
B) modifying factors
C) severity
D) location

Question 10

Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _____________ are assistants who may enter the information.

A) Transcriptionists
B) Scribes
C) Dictators
D) Nurses

Question 11

Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low-grade fever for the past four days. This is known as _______________.

A) subjective information
B) objective information
C) an assessment
D) a diagnosis

Question 12

Neil Rabinski was asked by the care provider if he has had any difficulty breathing, shortness of breath, or noticeable wheezing. This is part of the review of systems for the __________________ system.

A) gastrointestinal
B) head/eyes/ears/nose/throat
C) respiratory
D) cardiovascular

Question 13

The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?

A) musculoskeletal
B) gastrointestinal
C) neurologic
D) constitutional

Question 14

The healthcare professional who types reports for care providers is known as a/an ______________.

A) dictator
B) transcriptionist
C) transcriber
D) scribe

Question 15

The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient's visit.

A) care plan and charges
B) diagnosis and assessment
C) care plan, diagnosis, and assessment
D) care plan, charges, diagnosis, and assessment

Question 16

In a hospital setting, what document is the equivalent of the assessment and plan that is collected as part of a SOAP note in an outpatient record?

A) history and physical
B) discharge summary
C) progress note
D) procedure note

Question 17

Which of the following professionals would not perform a physical examination (PE)?

A) medical assistant
B) physician's assistant
C) nurse midwife
D) nurse practitioner

Question 18

Alison Holt just received a copy of her Clinical Visit Summary from the visit to her primary care provider earlier in the day. She is reading that her symptoms were present for the past four days and that she did not get any relief from Motrin. To which section of the SOAP note does this information pertain?

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 19

Dr. Schultz has just examined Natalia Shrier who had come to see him because she has been having increasing problems with gastroesophageal reflux. Dr. Schultz has instructed Natalia to avoid hot, spicy foods, to avoid eating within three hours of going to bed, to raise the head of her bed, and has given her an order to have an Upper GI x-ray. Dr. Schultz's instructions are part of which element in a SOAP note?

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 20

In a hospital setting, the care provider takes the patient's history, details the reason the patient is being admitted, and performs a physical exam. The report of this information is known as the:

A) initial progress note
B) discharge summary
C) history and physical
D) SOAP note

Question 21

A computerized system which allows physicians to request lab, radiology, or pharmacy services for their patients is known as

A) electronic health records.
B) computerized physician order entry.
C) electronic prescribing.
D) orders requisition.

Question 22

LaRhonda Howard is seen today by Dr. Bilkins for a chief complaint of recurrent abdominal pain and loss of appetite. Robert Drew is seen today by Dr. Bilkins for a chief complaint of follow-up for his poison ivy, which he was treated for last week. Which of these patients is likely to have a more extensive physical exam?

Question 23

Dr. Clark has just documented his findings of a physical exam performed on Patti Wolfe. She was seen today for productive cough. These findings are considered what kind of findings, as they relate to the SOAP note?

Question 24

Which of the following is a benefit of CPOE?

A) The results of a test are instantly received.
B) The patient receives his/her test results at the same time as the provider.
C) Clinical decision support is possible through CPOE.
D) Using CPOE is less costly for the patient.

Question 25

Of the following, which is a benefit of ePrescribing?

A) The patient's demographic and insurance information is sent to the pharmacy from the office.
B) There is less chance of medication errors being made.
C) It is less expensive for the patient.
D) Care providers and pharmacists are alerted to possible food/drug or drug/drug interactions.

Question 26

In order for any test, procedure, or medication to be administered to a patient, there must be a

A) SOAP note.
B) history and physical exam.
C) care provider's order.
D) consent from the patient.

Question 27

Relating to dictation, the technology that does recognize individual voices and does not improve over time is which kind of technology?

Question 28

Kelly is being seen by her physician today, and he is asking her if she's had any increase in or unusual headaches since her last visit, whether she has any blurred vision, and whether she has seen her eye doctor in the past year. The answers to these and other questions are documented in what part of the health record?

Question 29

In healthcare, when something is occurring at the time the patient is being seen, such as in ePrescribing, this is known as ____________________.

Question 30

How a patient is feeling, any current complaints or concerns, weight loss or gain, appetite, sleep patterns or difficulties, and a recap of vital signs are documented in the general part of the ROS and is also known as what?

Question 31

Of the following, which is an element of the history of present illness (HPI)?

A) duration
B) severity
C) quantity
D) quality

Question 32

Meaningful Use guidelines require the keeping of an up-to-date

A) dictation system.
B) chart note.
C) problem list.
D) past medical history.

Question 33

The extent of a physical exam will depend largely on the reason for the patient's visit, which is otherwise known as what?

Question 34

Tiffany Randall is seen by her physician after falling off a piece of playground equipment. She has a laceration on her chin. This is part of which element of the history of present illness?

Question 35

Emily Haver is being seen by Dr. Clark today for her annual physical exam. She has been a patient of his for many years. She is currently being treated for hypertension and type 2 diabetes mellitus. In the late 1990s she was treated on several occasions for poison ivy. She has been treated since 2003 with Zoloft for mild depression. Of the following, which will not appear on Emily Haver's problem list?

A) hypertension
B) diabetes
C) poison ivy
D) depression

Question 36

In Prime Suite, as with many other electronic health record systems, healthcare professionals and healthcare providers can access a patient's health record to determine the status of orders for testing or prescriptions. This is known as

A) computerized physician order entry.
B) order tracking.
C) discharge planning.
D) order status.

Question 37

If a computerized physician's order is sent to the local hospital for a blood test, and the physician's office has already been notified of the test findings, this order is

A) pending.
B) ordered.
C) returned.
D) scheduled.

Question 38

The fact that a patient has taken an over-the-counter medication and received relief of his pain is known as what in relation to the subjective documentation found in this patient's chart?

Question 39

In order for Dr. Reynolds to send a CPOE from her office computer system to the computer system at the local hospital, a/an ____________________ must exist between the two computer systems.

A) cable
B) interface
C) internet
D) firewall

Question 40

What is required in order for computerized physician order entry to occur between different healthcare facilities?

Question 41

Relate the reason(s) why voice recognition software is eventually more cost efficient for a physician's practice or hospital.

Question 42

What were the physical exam findings from the physical exam performed on Patti Wolfe?

Question 43

A history of present illness will usually consist of which elements?

Question 44

Explain why a problem list is maintained.

Question 45

What information is considered to be part of the history of present illness (HPI)?

Question 46

How does a patient whose care is rendered at a physician's office with computerized physician order entry capability benefit? Give an example.

Question 47

Why did the patient seek care?

Question 48

How does order tracking benefit the patient?

Question 49

Explain the difference between voice recognition and speech recognition technology. Why would one be preferred over the other by a care provider?

Question 50

Explain the benefits of ePrescribing.

Question 51

Explain why a care provider's dictated and transcribed report would be more beneficial than a handwritten note.

Question 52

What information is considered to be part of the review of systems (ROS)?