CCS Electronic Health Records & Documentation 2 — Questions and Answers
Question 1: Which federal law established the legal framework for EHR adoption and Meaningful Use incentives?
- HIPAA
- HITECH Act (Correct answer)
- ACA
- MACRA
Correct answer: HITECH Act
The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 promoted EHR adoption through Meaningful Use incentive programs.
Question 2: When documenting a patient's refusal of medication in an EHR, the care specialist should:
- Leave the entry blank and retry later
- Document the refusal, reason given, and any education provided (Correct answer)
- Note only that medication was not given
- Notify the pharmacy without documenting in the chart
Correct answer: Document the refusal, reason given, and any education provided
Complete documentation of a refusal includes the patient's reason, any education provided, and the care provider notified.
Question 3: An EHR audit trail records which of the following?
- Patient billing preferences only
- Who accessed or modified a record and when (Correct answer)
- Laboratory supply inventory
- Insurance pre-authorization codes
Correct answer: Who accessed or modified a record and when
Audit trails log user access, edits, deletions, and timestamps to ensure accountability and detect unauthorized activity.
Question 4: Which data entry method reduces transcription errors in EHR documentation?
- Handwritten notes scanned later
- Structured data entry using standardized drop-down menus (Correct answer)
- Faxing paper forms to the records department
- Verbal-only reporting at shift change
Correct answer: Structured data entry using standardized drop-down menus
Structured data entry with standardized fields minimizes free-text errors and supports consistent, searchable clinical data.
Question 5: In an EHR, a 'problem list' is best described as:
- A list of all scheduled appointments
- An ongoing record of active and chronic conditions relevant to the patient's care (Correct answer)
- A log of complaints filed by the patient
- A summary of completed procedures only
Correct answer: An ongoing record of active and chronic conditions relevant to the patient's care
The problem list is a dynamic summary of current, chronic, and significant past conditions that guides ongoing care decisions.
Question 6: Which action best protects EHR security when a care specialist steps away from a workstation?
- Minimizing the browser window
- Logging out or locking the screen (Correct answer)
- Turning off the monitor
- Closing all open patient tabs
Correct answer: Logging out or locking the screen
Logging out or activating the screen lock prevents unauthorized access to patient records when a workstation is unattended.
Question 7: When correcting an error in an EHR, the correct approach is to:
- Delete the original entry completely
- Overwrite the incorrect entry without notation
- Add an addendum with the correct information and reason for correction (Correct answer)
- Ask a colleague to re-enter the data under their login
Correct answer: Add an addendum with the correct information and reason for correction
Errors are corrected by addendum, preserving the original entry and documenting who made the correction and why.
CCS Electronic Health Records & Documentation 2
Which federal law established the legal framework for EHR adoption and Meaningful Use incentives?