CEHRS Clinical Workflow and Documentation 2 — Questions and Answers
Question 1: A nurse documents a patient's fall in the EHR after the incident occurred. Which documentation practice is being demonstrated?
- Prospective documentation
- Late entry documentation (Correct answer)
- Addendum entry
- Interval documentation
Correct answer: Late entry documentation
Late entry documentation refers to recording clinical information after the event occurred, and it should be clearly labeled as such with the reason for the delay.
Question 2: Which EHR feature automatically checks for drug-drug interactions when a provider enters a new prescription?
- Clinical decision support (CDS) (Correct answer)
- Computerized physician order entry (CPOE)
- Electronic medication administration record (eMAR)
- Formulary management
Correct answer: Clinical decision support (CDS)
Clinical decision support systems analyze orders in real time and alert providers to potential drug-drug interactions before medications are dispensed.
Question 3: What is the purpose of a problem list in the EHR?
- To list all scheduled appointments
- To document active and chronic conditions being managed (Correct answer)
- To track pending laboratory orders
- To record all past surgical procedures only
Correct answer: To document active and chronic conditions being managed
The problem list is a dynamic section of the EHR that captures active, chronic, and resolved conditions that are relevant to the patient's ongoing care.
Question 4: During medication reconciliation, a discrepancy is found between a patient's home medications and the hospital admission orders. What is the correct first step?
- Administer the ordered medication immediately
- Notify the prescribing provider to resolve the discrepancy (Correct answer)
- Document the discrepancy and wait for shift change
- Delete the conflicting entry from the EHR
Correct answer: Notify the prescribing provider to resolve the discrepancy
Medication reconciliation discrepancies must be promptly communicated to the prescribing provider for clinical review and resolution before medications are administered.
Question 5: Which of the following is an example of structured data entry in an EHR?
- A physician's narrative note describing symptoms
- Selecting a diagnosis from a drop-down ICD-10 code list (Correct answer)
- Scanning a handwritten prescription into the chart
- Uploading an external PDF referral letter
Correct answer: Selecting a diagnosis from a drop-down ICD-10 code list
Structured data entry uses predefined fields, checkboxes, and drop-down menus—such as selecting an ICD-10 code—enabling standardized, searchable, and reportable data.
Question 6: A patient's allergy to penicillin is documented in the EHR. A provider orders amoxicillin. Which system should alert the provider?
- Laboratory information system
- Clinical decision support with allergy checking (Correct answer)
- Revenue cycle management system
- Scheduling module
Correct answer: Clinical decision support with allergy checking
Clinical decision support with allergy-checking functionality cross-references active orders against documented allergies and issues an alert for cross-reactive drugs like amoxicillin.
Question 7: What does 'chart pull' refer to in the context of transitioning from paper to electronic records?
- Retrieving a physical paper chart for scanning or reference (Correct answer)
- Downloading data from a remote EHR server
- Printing a complete electronic health record
- Pulling a patient's insurance information from a payer portal
Correct answer: Retrieving a physical paper chart for scanning or reference
Chart pull is the process of physically retrieving a paper medical record, often performed during EHR implementation to scan historical documents into the new system.
CEHRS Clinical Workflow and Documentation 2
A nurse documents a patient's fall in the EHR after the incident occurred.
Which documentation practice is being demonstrated?