OPS 571 Week 4 Quiz

OPS 571 Week 4 Quiz

A practice that is implementing an EHR system should review ______ laws before deciding on which type of electronic signature to include. - State

Which of the following statements about accreditation standards is correct? - Compliance with them is voluntary.

Which of the following data sets is intended to reflect that the most relevant data in a patient's record is transmitted from one health care provider to another? - CCR

Which of the following data sets may be used by employers to compare managed care plans? - HEDIS

Which of the following statements best follow the guidelines regarding EHR signatures? - Only the originator of an entry should apply the signature to their entry.

Which of the following statements about the use of abbreviations is correct? - Using medical abbreviations can save time.

Medical offices may develop their own abbreviations for common practices.

When used incorrectly, abbreviations can harm a patient. All of the above are correct.

What is the primary purpose of a patient health record? - To provide documented evidence of care

All of the following are examples of administrative data except: - Patient's medication list

The Joint Commission list tells health care providers not to use the abbreviation _____, but to instead write _______. - QOD, every other day

Which of the following abbreviations are acceptable to use in charting? - 0.5 mg

A provider orders a chest x-ray based on his examination findings. What record purpose is associated with this order? - Provide support for clinical decisions

Based on The Joint Commission Standard and Performance Elements for Signatures, how may authentication of a signature be verified? - Through an electronic signature   Through written initials 

 Through a computer key 

 All of the above

The Conditions of Participation is an example of a(n) ________ standard. - certification A(n) _______ record organizes information by each type of recording. - integrated

A document keyed by a medical transcriptionist is introduced into a patient's clinical record. Which of the following statements regarding this information is correct? - The practitioner who dictated the information must authenticate the transcribed entry.

When viewing a patient record in an EHR system, how will the user know if data has been changed? - The user will see a "modified" notation associated with any changes.

What does the "A" in SOAP notes stand for? - assessment

A medical office that is in the process of implementing an EHR system should be aware that which of the following standard documentation practices will be different than what they were previously accustomed to when moved to the EHR environment? - Guidelines for correcting errors

All of the following are examples of credible resources for building an EHR data dictionary abbreviations list except: - The Federal Abbreviations Standard

Which type of health record standard varies depending on the state in which the practice is located? - Licensure

One of a number of voluntary organizations providing standards for and evaluating care in ambulatory care facilities; this organization focuses entirely on various types of ambulatory care settings - Accreditation Association for Ambulatory Health Care

AAAHC

Guidelines developed by independent non-profit groups that apply to health care facilities that voluntarily choose to comply - Accreditation standards

Patient record organized by patient problems numbered in order as they are identified with all recording referring back to the specific problem through documentation of its number - problem oriented record

Defined set of information that is found in ambulatory records outlined by the National Committee for Quality Assuranc