FREE EHR System and Regulations Questions and Answers
Notes about a patient's medical condition that are made during or after a physician-patient encounter:
Explanation:
Progress notes are written documentation of a patient's medical condition that are made during or after a physician-patient encounter. These notes include information about the patient's symptoms, diagnosis, treatment plan, and any changes in their condition. Progress notes are important for tracking the patient's progress over time and for communication between healthcare providers. They help ensure continuity of care and provide a comprehensive record of the patient's medical history. E/M codes, on the other hand, are used to classify the level of complexity of a patient encounter for billing purposes.
Which of the following is a feature of a patient portal within an EHR?
Explanation:
A patient portal is an online application that allows patients to interact with their healthcare providers and access their health information securely. One of the key features of a patient portal within an EHR is that patients can input health status updates between appointments. This allows healthcare providers to monitor patient’s conditions more closely and make timely interventions if necessary. The ability to update health status can include information such as symptoms, daily health measurements, or changes in conditions, which helps in maintaining a continuous and comprehensive record of the patient's health. The other options, while useful in a healthcare context, are not typically primary features of patient portals.
A widely used format for documenting patient encounters:
Explanation:
SOAP is a widely used format for documenting patient encounters. It stands for Subjective, Objective, Assessment, and Plan. The SOAP format provides a structured way for healthcare professionals to record and communicate important information about a patient's condition, including subjective information from the patient, objective findings from examinations and tests, assessments or diagnoses made by the healthcare provider, and plans for further treatment or management. By using the SOAP format, healthcare professionals can ensure that all relevant information is documented in a systematic and organized manner, facilitating effective communication and continuity of care.
What science studies the storage and analysis of health data?
Explanation:
Health informatics is the correct answer because it is the science that studies the storage and analysis of health data. Health informatics combines the fields of healthcare, information technology, and data analysis to improve the management and utilization of health information. It involves the collection, storage, retrieval, and analysis of health data to support decision-making, research, and healthcare delivery. Health informatics plays a crucial role in improving healthcare outcomes, managing patient records, and facilitating evidence-based practices.
Which of the following is an example of a static report?
Explanation:
A static report provides information that remains fixed over time. In this case, the birth register for a particular day is an example of a static report because it captures data at a specific point in time and does not change unless manually updated. The other options involve dynamic data that can change frequently, such as the number of patients currently hospitalized, the current number of delinquent medical records, and the patients list sorted by insurance carrier.
A patient presents to a provider’s office with a third-degree burn on his hand from cooking oil, which of the following should an EHR specialist code first?
Explanation:
Classifying the burn correctly is critical for determining its severity and subsequent treatment. In this case, a third-degree burn indicates the highest level of tissue damage, requiring specialized care. Properly documenting the classification ensures accurate medical records, appropriate treatment plans, and billing procedures. While noting the location is also important, accurately classifying the burn takes precedence in this scenario.
Healthcare professionals and organizations that provide health care in the normal course of business and electronically transmit any information that is protected under HIPAA:
Explanation:
Covered entities refer to healthcare professionals and organizations that provide healthcare services and transmit protected health information electronically. These entities are required to comply with the regulations and standards set by HIPAA (Health Insurance Portability and Accountability Act) to ensure the privacy and security of patients' health information. Therefore, the correct answer is covered entities.
Information that neither identifies nor provides a reasonable basis to identify an individual.
Explanation:
De-identified health information refers to health data that has been stripped of any identifiers or information that could be used to reasonably identify an individual. This means that the data has been anonymized and does not pose a risk to the privacy or confidentiality of the individuals involved. It is considered a safe and secure way to share health information for research, analysis, and other purposes without violating any privacy regulations.
The following are the advantages of electronic records in ambulances, except:
Explanation:
The advantages of electronic records in ambulances include the ability to review clinical standards, share patient data, and provide better training for paramedics. However, procurement of facilities is not directly related to electronic records and does not provide any specific advantage in this context.
Which of the following is a benefit of documenting a patient encounter at the point of care?
Explanation:
Documenting a patient encounter at the point of care means recording information about the patient's condition and treatment in real-time, during the patient visit. This practice ensures that accurate and up-to-date information is captured immediately, which can improve the quality of care. Immediate documentation helps prevent errors, ensures continuity of care, and allows for timely decision-making, all of which contribute to improved patient outcomes. While diminished wait times might be a secondary benefit, the primary advantage is the enhancement of patient care quality and outcomes.
In which of the following areas of a patient's EHR will the EHR specialist find the necessary documentation to substantiate a short-term disability claim for a woman on Maternity Leave?
Explanation:
Nurses Notes provide detailed, day-to-day documentation of the patient's condition, treatment, and response to care. These notes can include vital signs, pain levels, mobility, and other observations that are critical for substantiating a short-term disability claim, particularly for maternity leave. This ongoing record is essential for providing comprehensive evidence of the patient's need for continued time off work.