Ambulatory Care Test Documentation and Health Records 2 — Questions and Answers
Question 1: Which component of the EHR is used to document a patient's preferences regarding life-sustaining treatment in ambulatory care?
- Problem list
- Advance directive (Correct answer)
- Medication reconciliation form
- Referral order
Correct answer: Advance directive
Advance directives document a patient's wishes about life-sustaining treatment and should be scanned and stored in the EHR.
Question 2: What is the primary purpose of medication reconciliation at ambulatory care transitions of care?
- To reduce prescription costs for the patient
- To identify and resolve medication discrepancies between care settings (Correct answer)
- To update the pharmacy's dispensing records
- To obtain prior authorizations for medications
Correct answer: To identify and resolve medication discrepancies between care settings
Medication reconciliation prevents errors by comparing a patient's medication orders across care settings to identify omissions, duplications, and discrepancies.
Question 3: A nurse documents a patient's pain as 7/10 before and 3/10 after analgesia. Which charting system does this reflect?
- Narrative charting
- Charting by exception
- Focus charting (DAR) (Correct answer)
- SOAP note
Correct answer: Focus charting (DAR)
Focus charting (DAR: Data, Action, Response) organizes documentation around a patient concern and documents the data, nursing action, and patient response.
Question 4: Which of the following is an example of a minimum necessary disclosure under HIPAA in ambulatory care?
- Sending a patient's complete medical history to a life insurance company
- Providing only relevant lab results to a referring specialist (Correct answer)
- Sharing all chart notes with an employer requesting a work clearance
- Faxing the full EHR to a patient's attorney without authorization
Correct answer: Providing only relevant lab results to a referring specialist
The minimum necessary standard requires that only the information required for the specific purpose be disclosed, such as relevant labs to a specialist.
Question 5: An ambulatory care nurse documents that a patient 'appears anxious.' This is an example of which type of data?
- Subjective data
- Objective data (Correct answer)
- Diagnostic data
- Historical data
Correct answer: Objective data
Observable nurse assessments like patient appearance are objective data because they represent directly measurable or observable findings.
Question 6: Which of the following best describes the purpose of the problem list in an ambulatory EHR?
- To list all medications ordered during a visit
- To provide a longitudinal summary of active diagnoses and chronic conditions (Correct answer)
- To document the reason for today's visit only
- To record completed referrals and specialist notes
Correct answer: To provide a longitudinal summary of active diagnoses and chronic conditions
The problem list serves as a running summary of active and chronic conditions, providing continuity across all encounters in the ambulatory record.
Ambulatory Care Test Documentation and Health Records 2
Which component of the EHR is used to document a patient's preferences regarding life-sustaining treatment in ambulatory care?