CEHRS Clinical Workflow and Documentation 2

Question 1

A nurse documents a patient's fall in the EHR after the incident occurred. Which documentation practice is being demonstrated?

Accepted Answer

Late entry documentation

Answer

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?

Accepted Answer

Clinical decision support (CDS)

Answer

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?

Accepted Answer

To document active and chronic conditions being managed

Answer

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?

Accepted Answer

Notify the prescribing provider to resolve the discrepancy

Answer

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?

Accepted Answer

Selecting a diagnosis from a drop-down ICD-10 code list

Answer

Structured data entry uses predefined fields, checkboxes, and drop-down menus—such as selecting an ICD-10 code—enabling standardized, searchable, and reportable data.

(CEHRS) Certified Electronic Health Records Specialist Practice Test

(CEHRS) Certified Electronic Health Records Specialist Practice Test

CEHRS Clinical Workflow and Documentation 2