Chapter 01: Introduction to Electronic Health Records
Pepper: The Electronic Health Record for the Physician’s Office for SimChart® for the Medical Office, 3rd Edition

MULTIPLE CHOICE

	1.	A collection of an individual’s healthcare information is termed:
a.	patient chart.	
b.	patient record.	
c.	electronic health record.	
d.	EMR.	
e.	All of the options.	

ANS:	E
All of the above are collections of an individual patient’s health data.

REF:	p. 3	OBJ:	1

	2.	Early medical documentation of present day posttraumatic stress syndrome was first seen in:
a.	the U.S. Civil War.	
b.	the plagues of Europe.	
c.	200 BC China.	
d.	the Korean War.	
e.	WWII.	

ANS:	A
Posttraumatic stress syndrome was first documented as “nervous disease” during the U.S. Civil War.

REF:	p. 2	OBJ:	1

	3.	Which of the following is NOT found in the patient medical record?
a.	Immunization records	
b.	Operative reports	
c.	Living will	
d.	Patient statement	
e.	Referral letters	

ANS:	D
Immunization records, operative reports, living wills, and referral letters are all common contents of the patient record.

REF:	pp. 3-4	OBJ:	2

	4.	An example of a HIPAA form that is included in the medical record would be:
a.	a patient information sheet.	
b.	a living will.	
c.	a Notice of Privacy Practices acknowledgement.	
d.	informed consent forms.	
e.	H&P.	

ANS:	C
HIPAA requires that all patients be provided with the Notice of Privacy Practices and that the provider document that the patient has received the notice. That acknowledgement must be included in the medical record.

REF:	p. 4	OBJ:	2

	5.	An individual who is responsible for recording data in the patient record is called a:
a.	transcriber.	
b.	health records clerk.	
c.	data entry clerk.	
d.	documenter.	
e.	guarantor.	

ANS:	D
Documenter is the term given to an individual who places information into the patient chart.

REF:	p. 6	OBJ:	3

	6.	Which of the following is NOT a documenter of the patient chart?
a.	Provider	
b.	Patient	
c.	Medical assistant	
d.	Medical billing specialist	
e.	All of the options	

ANS:	B
The patient will verbalize the information for the chart but does not directly provide documentation in the chart.

REF:	p. 6	OBJ:	3

	7.	When accompanying a patient into the exam room, the MA commonly documents the:
a.	plan of treatment.	
b.	reason for no show.	
c.	chief complaint.	
d.	patient billing information.	
e.	diagnosis.	

ANS:	C
The medical assistant commonly documents vital signs, HPI, medications, known allergies, and chief complaint (reason for visit).

REF:	p. 6	OBJ:	3

	8.	Practice management software:
a.	may be included as part of an interoperable EHR.	
b.	includes administrative functions like appointment books and billing.	
c.	must be purchased separate from the clinical EHR.	
d.	is where clinical documentation occurs.	
e.	May be included as part of an interoperable EHR and includes administrative functions like appointment books and billing.	

ANS:	E
PMS is often included as part of an interoperable EHR system.

REF:	p. 10	OBJ:	6

	9.	Voice recognition software:
a.	will increase transcription costs for the medical office.	
b.	automatically converts a documenter’s spoken word into written words.	
c.	has a quick implementation and requires very little training.	
d.	may increase errors because there is no assistant to review the notation.	
e.	All of the options.	

ANS:	B
Voice recognition software decreases error and costs for the medical office. There is a training period for the software to identify the speaker’s dialect.

REF:	p. 4	OBJ:	2

	10.	The receptionist would commonly document:
a.	patient vital signs.	
b.	patient no-shows.	
c.	diagnosis of the patient condition.	
d.	results of tests performed.	
e.	hospital orders.	

ANS:	B
The receptionist documents administrative information such as appointment times, prescription refills, reasons for visits, no shows, and cancellations.

REF:	p. 6	OBJ:	2

	11.	Owner of the physical medical record:
a.	is always the provider.	
b.	is always the patient.	
c.	is the hospital the provider admits to.	
d.	is the one who creates and maintains the record.	
e.	is always the EHR vendor.	

ANS:	D
The physical medical record is owned by the one who creates the document. The patient owns the information and may request a copy at any time.

REF:	p. 6	OBJ:	4

	12.	In SimChart for the Medical Office, a patient visit with a provider is called a(n):
a.	visit.	
b.	progress note.	
c.	encounter.	
d.	interaction.	

ANS:	C
A patient/provider visit is called an “encounter” in SimChart for the Medical Office.

REF:	p. 3	OBJ:	2

	13.	Which of the following professional organization is made up of health information management professionals?
a.	AMA	
b.	AAPC	
c.	AMT	
d.	AAMA	
e.	AHIMA	

ANS:	E
The American Health Information Management Association (AHIMA) is the professional organization made up of health information management professionals.

REF:	p. 19	OBJ:	10

	14.	Which of the following professional organization has identified the use of computers and electronic equipment in the medical office as one of its key competencies?
a.	AMA	
b.	AAPC	
c.	AMT	
d.	AAMA	
e.	AHIMA	

ANS:	D
Since 2007 the American Association of Medical Assistants (AAMA) has identified the use of computers and electronic equipment in the medical office as one of its key competencies.

REF:	p. 20	OBJ:	10

	15.	With the implementation of an EHR, it is helpful if employees can be ___________ so that they are able to perform more than one duty within the EHR.
a.	fully supported	
b.	team leaders	
c.	cross-trained	
d.	out-sourced	
e.	None of the options	

ANS:	C
Being crossed-trained on the EHR would allow for one employee to help out if another employee calls in sick or to even help out over lunch or break times.

REF:	p. 18	OBJ:	9

	16.	Which of the following is a disadvantage of EHRs?
a.	Patient support	
b.	Initial investment	
c.	Security	
d.	Standardized information	
e.	Decision support	

ANS:	B
The initial investment needed to implement an EHR can be considered a disadvantage.

REF:	p. 16	OBJ:	8

	17.	The Meaningful Use (MU) incentive program requirements can help with tracking incidences of the swine flu. This can be monitored with the help of which MU objective?
a.	Medication reconciliation	
b.	Computerized provider order entry	
c.	Health information exchange	
d.	Electronic messaging	
e.	Public health reporting	

ANS:	E
Diagnoses of infectious diseases can be reported confidentially to public health authorities, and researchers can access EHR databases to gather epidemiologic statistics using the reporting and population health core function.

REF:	p. 8	OBJ:	7

	18.	_________ allows providers to tailor the care of an individual patient by making sure it adheres to published guidelines for the patient’s specific diagnoses.
a.	CDS	
b.	HIPAA	
c.	CPOE	
d.	MU	
e.	ONC	

ANS:	A
Clinical decision support tools allow the provider to tailor care for a specific patient case.

REF:	p. 9	OBJ:	5

	19.	The fixed amount of money a patient is contracted to pay out of pocket at each visit is called:
a.	the deductible.	
b.	the patient payment.	
c.	the copayment.	
d.	coinsurance.	
e.	the self-pay portion.	

ANS:	C
The copayment is listed on the patient’s insurance card. The patient is responsible for this amount each time he/she sees the provider.

REF:	p. 10	OBJ:	6

	20.	Practice management software does all of the following except:
a.	scheduling appointments.	
b.	documenting patient visit results.	
c.	creating patient statements.	
d.	storing patient demographics.	
e.	documenting appointment cancellations.	

ANS:	B
PMS would not document progress notes (patient visits). This would be a function of the EHR.

REF:	p. 10	OBJ:	6

	21.	An established patient:
a.	has not been seen by a provider in the practice within the past 3 years.	
b.	has not been seen by a provider in the practice within the past 5 years.	
c.	has been seen by a provider in the office within the past 5 years.	
d.	has been seen by a provider in the office within the past 4 years.	
e.	has been seen by a provider in the office within the past 3 years.	

ANS:	E
An established patient is one who has been seen by a provider in the office within the past 3 years.

REF:	p. 11	OBJ:	7

	22.	Which of the following would be documented using computerized provider order entry (CPOE)?
a.	E-prescribing	
b.	Appointments	
c.	Patient correspondence	
d.	Patient services	
e.	Email correspondence	

ANS:	A
E-prescribing is an example of computerized provider order entry (CPOE).

REF:	p. 8	OBJ:	5

	23.	The form used to gather data about the patient, including basic demographic information, and payer information is called the:
a.	patient copayment form.	
b.	patient information form.	
c.	patient statement.	
d.	day sheet.	
e.	day journal.	

ANS:	B
The patient information form contains all of the basic demographic information, payer information, and emergency contact.

REF:	p. 10	OBJ:	6

	24.	The ___________ is a statement for the daily business transactions. It includes the list of checks and balances for the office for a specific date of service.
a.	patient copayment form	
b.	patient information form	
c.	patient statement	
d.	day sheet	
e.	None of the options	

ANS:	D
A day sheet or day journal is a register of daily business transactions. A patient statement is a document that contains a patient’s identifying and contact information, appointment details, payments made, insurance reimbursements received, balance owed, and amount outstanding. A patient statement report is a list of the outstanding balances for all appointments up to the current date.

REF:	p. 11	OBJ:	6

	25.	What is the standard electronic format that facilitates the claims processing for providers and suppliers?
a.	CMS 1500 claim form	
b.	Patient statement	
c.	Day sheet	
d.	HIPAA 5010	
e.	EOB	

ANS:	D
The electronic format for the submission of claims is called a HIPAA 5010.

REF:	p. 11	OBJ:	6

	26.	Which of the following healthcare professionals will be users of the EHR?
a.	Physicians	
b.	Nurses	
c.	Medical assistants	
d.	Coders	
e.	All of the options	

ANS:	E
Physicians, nurses, physician’s assistants, medical assistants, and medical coders and billers will all be users of the EHR.

REF:	p. 18	OBJ:	9

	27.	Skills for using the EHRs include:
a.	knowledge of medical terminology.	
b.	math skills.	
c.	empathy.	
d.	flexibility.	
e.	setting priorities.	

ANS:	A
Skills helpful for using the EHR include knowledge of medical terms, organizational skills, basic typing and computer skills, and interpersonal skills.

REF:	p. 18	OBJ:	9

	28.	Healthcare Business Monthly is published by:
a.	AAPC.	
b.	AHIMA.	
c.	CMS.	
d.	AAMA.	
e.	CDC.	

ANS:	A
The American Academy of Professional Coders publishes The Coding Edge monthly for members.

REF:	p. 19	OBJ:	10

ESSAY

	1.	List four examples of clinical records found in the patient chart.

ANS:	
Answers may include medication lists, allergy lists, immunization records, lab and pathology records, surgical reports, hospital records, H&P, progress notes, and imaging results.

REF:	p. 3	OBJ:	2

	2.	List four types of administrative functions in the EHR.

ANS:	
Answers may include patient and nonpatient scheduling; composing emails, letters, and phone messages; completing forms such as patient information, referral, and consultation forms; and entering and maintaining patient demographics.

REF:	p. 3	OBJ:	2

	3.	Describe the doctrine of professional discretion. Include an example of when it might be used.

ANS:	
This principle states that providers can exercise their best judgment when deciding whether or not to share progress notes and clinical observations with a patient who is being treated for mental or emotional disturbances. The doctrine of professional discretion is intended to protect mentally or emotionally ill patients from any additional harm that viewing their medical records could cause. For example, a fragile patient who is depressed or suicidal may be upset to read the provider’s assessment of his or her unstable condition.

REF:	p. 7	OBJ:	4

	4.	List the disadvantages of using an EHR.

ANS:	
Answers may include lack of interoperability, high cost of initial investment in time and money, resistance from some employees, regimentation as a result of using standardized templates to document patient care, and security gaps attributable to the electronic availability of confidential patient information.

REF:	pp. 15-16	OBJ:	8

	5.	What is the difference between the EHR and EMR?

ANS:	
The EMR was said to be an electronic patient record created and maintained by a medical practice or hospital, whereas the EHR was said to be an interconnected aggregate of all the patient’s health records, culled from multiple providers and healthcare facilities. In other words, the EMR was said to be a component of the EHR.

REF:	p. 8	OBJ:	5

	6.	Describe some common reasons providers fail to use the clinical decision support tool.

ANS:	
If information is not entered properly, some CDS functions are less effective. Providers may ignore system-generated advice either because they’re busy or because they prefer to rely on their own judgment and experience. Some practices may not even install this function, especially if there is no financial incentive for delivering care in conformity with established protocols.

REF:	p. 9	OBJ:	5

	7.	List advantages of electronic health records.

ANS:	
The advantages of using an EHR system include improved quality and continuity of care, increased efficiency, improved documentation, easier point-of-care accessibility, better security, reduced expenses, improved job satisfaction for providers and staff, and improved patient satisfaction.

REF:	pp. 11-14	OBJ:	7

	8.	List some of the benefits of belonging to a professional organization.

ANS:	
Professional organizations offer certification exams; provide a wide range of continuing education opportunities; provide a forum to network with other professionals; publish periodicals; offer discounts on publications; and sponsor conferences, workshops, and Web-based activities.

REF:	p. 19	OBJ:	10

	9.	List the four main goals of the Meaningful Use (MU) program.

ANS:	
To improve quality, safety, and efficiency and reduce health disparities; engage patients and family; improve care coordination, population, and public health; and maintain privacy and security of patient health information.

REF:	p. 7	OBJ:	5

TRUE/FALSE

	1.	Medical records for immigrants in Ellis Island were used to document communicable disease.

ANS:	T
Documentation was kept in medical records to determine the presence or absence of communicable disease.

REF:	p. 2	OBJ:	1

	2.	Maintaining patient records is optional for healthcare providers.

ANS:	F
Documentation in a record is required for patient encounters by the healthcare provider.

REF:	p. 3	OBJ:	3

	3.	The contents of the patient health record are standardized from office to office.

ANS:	F
The contents are generally very similar; however, the information will vary some from office to office.

REF:	p. 3	OBJ:	2

	4.	The medical assistant is a frequent documenter of the patient record.

ANS:	T
Documenting in the patient record is a common duty of the medical assistant.

REF:	p. 6	OBJ:	3

	5.	Information that is documented in the electronic patient chart may be handwritten.

ANS:	F
Documentation may be handwritten, dictated in a paper chart, but electronic charting will require structured or unstructured data entry.

REF:	p. 4	OBJ:	3

	6.	The patient is the owner of the health record.

ANS:	F
The entity who creates and maintains the record is the owner of the patient record (generally the provider, medical office, or EHR vendor). The patient owns the data and has the right to request a copy.

REF:	p. 6	OBJ:	4

	7.	A medical office may charge for the copying of medical records. Because the information belongs to the patient, the copies may not be withheld for any reason.

ANS:	T
The office may charge an administrative fee for copying/printing the records.

REF:	p. 6	OBJ:	4

	8.	Data entry into the EHR using voice recognition, electronic sentence building, and structured data entry is electronic transcription.

ANS:	T
Electronic transcription in the EHR can occur several different ways, including voice recognition software, electronic sentence building, radio buttons, drop-down boxes, and free text entry.

REF:	p. 4	OBJ:	3

	9.	The roles of healthcare professionals do not change with the implementation of the EHR.

ANS:	F
The roles of many healthcare professionals do change with the implementation of the EHR. All roles must be evaluated and refined to ensure a smooth transition to an electronic records system.

REF:	p. 18	OBJ:	9

	10.	An established patient is one who has been seen by a member of the healthcare team within the past 4 years.

ANS:	F
An established patient is one who has been seen within the past 3 years. If it has been more than 3 years since the patient was seen, he/she would be considered a new patient.

REF:	p. 11	OBJ:	5

	11.	The implementation of an electronic health record usually increases patient satisfaction for the medical office.

ANS:	T
Patient satisfaction is one of the advantages of EHR implementation.

REF:	p. 15	OBJ:	7

	12.	Introducing the electronic health record into the provider’s office will result in little to no employee resistance.

ANS:	F
Staff resistance is one of the common disadvantages of the EHR.

REF:	p. 16	OBJ:	8

	13.	Power outages, viruses, backup procedures, and computer freezes and crashes pose other safety and security concerns for medical offices using EHRs.

ANS:	T
Security gaps are a major concern for providers’ offices.

REF:	p. 17	OBJ:	8