Ambulatory Care Test Documentation and Health Records 2

Question 1

Which component of the EHR is used to document a patient's preferences regarding life-sustaining treatment in ambulatory care?

Accepted Answer

Advance directive

Answer

Problem list

Answer

Medication reconciliation form

Answer

Referral order

Question 2

What is the primary purpose of medication reconciliation at ambulatory care transitions of care?

Accepted Answer

To identify and resolve medication discrepancies between care settings

Answer

To reduce prescription costs for the patient

Answer

To update the pharmacy's dispensing records

Answer

To obtain prior authorizations for medications

Question 3

A nurse documents a patient's pain as 7/10 before and 3/10 after analgesia. Which charting system does this reflect?

Accepted Answer

Focus charting (DAR)

Answer

Narrative charting

Answer

Charting by exception

Answer

SOAP note

Question 4

Which of the following is an example of a minimum necessary disclosure under HIPAA in ambulatory care?

Accepted Answer

Providing only relevant lab results to a referring specialist

Answer

Sending a patient's complete medical history to a life insurance company

Answer

Sharing all chart notes with an employer requesting a work clearance

Answer

Faxing the full EHR to a patient's attorney without authorization

Question 5

An ambulatory care nurse documents that a patient 'appears anxious.' This is an example of which type of data?

Accepted Answer

Objective data

Answer

Subjective data

Answer

Diagnostic data

Answer

Historical data

Question 6

Which of the following best describes the purpose of the problem list in an ambulatory EHR?

Accepted Answer

To provide a longitudinal summary of active diagnoses and chronic conditions

Answer

To list all medications ordered during a visit

Answer

To document the reason for today's visit only

Answer

To record completed referrals and specialist notes