Last Updated 05 Jan 2018

Integrated Electronic Health Records Chapters 4 & 5

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You have just entered data into an online form. The box in which you entered the information is known as a/an:
Every form should include the _______________ so that the form's use is obvious.
form name
Of the following, which is not part of the patient's past medical or surgical history?
marital status
Which of the following typically would not be collected as part of the past surgical history?
name of the anesthesiologist
Natalie Burns has just arrived for her 1:00 p.m.

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. Earl. She informs the healthcare professional that she is there for a follow-up of her hypertension. This is known as Natalie's:
chief complaint
Craig James is in the office of Dr. Hammer for his annual physical. Dr. Hammer asks Craig a series of questions such as "do you have frequent headaches," "do you have frequency of urination," and "do you have difficulty sleeping." These questions are part of the:
Review of Systems (ROS)
Emily Haver documented on her past history form that she had an arthroscopy of the right knee in 2005. On her next visit, the care provider was reviewing her past surgical history and mentioned that she had had right knee arthroscopy. The patient realized she had written the wrong side, and confirmed that it was her left knee which underwent arthroscopy. What action will the care provider take in this case?
Amend the record to show the corrected information, according to office policy.
Which of the following is not a vital sign?
complete blood count
The "box" where data is entered on an electronic medical record, for instance Patient's Last Name, is commonly called a field. What is the other name for field?
What are the two pieces of data that should be on every page of a paper record, even on the front and the back, if a two-sided document in order to ensure each form is on the correct patient's record?
The patient's full name and his/her chart (medical record) number.
Sarah Armel has been a smoker for 15 years. She smokes 1 pack per day. This is noted in which section of Sarah's history?
social history
What information within the history may be a predictor of the patient's future health?
family history
Explain why electronic forms may not replace paper forms entirely.
Because not all patients have a computer, know how to use a computer, or are willing to complete a computer screen. In addition, some lingering concerns about data privacy may cause some practices to retain paper as a form of data collection.
You are designing a registration form. The patient's employer is a data field. What related data might you also collect regarding the patient's employer and why?
Key pieces of data are name of employer, address of employer, phone number, position within the company, and how long the patient has been with the company.
Explain how EHR software, ensures the correction or amendment to an electronic record is made without jeopardizing the integrity of the record.
The original version remains in the system and is retrievable at any time. It is never truly deleted.
Explain why each page of a multipage form should include the patient's name and the medical record number.
To guard against mixing up the records of patients with the same or similar names and to guard against documentation errors in general.
A medical practice or hospital must have _________________ on how to handle inconsistent or unclear information.
written policies
results of a patient's rapid strep test would be found in what area of a SOAP note?
healthcare professionals and healthcare providers can access a patient's health record to determine the status of orders for testing or prescriptions. This is known as:
orders tracking
Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low grade fever for the past four days. This is known as
subjective information
"Of the following, which is not an element of the history of present illness (HPI)?
A. duration
B. severity
C. quantity
D. quality
"Of the following, which is not a benefit of ePrescribing?
A. the patient's demographic and insurance information is sent to the pharmacy from the office
B. there is less chance of medication errors being made
C. it is less expensive for the patient
D. care providers and pharmacists are alerted to possible food/drug or drug/drug interactions
it is less expensive for the patient
Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Philips, by typing the sentences: "The patient is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He voices no other complaints." This is an example of _________________ data.
In a hospital setting, the care provider takes the patient's history, details the reason the patient is being admitted and performs a physical exam. The report of this information is known as the:
history and physical
The results of a patient's rapid strep test would be found in what area of a SOAP note?
The SOAP documentation format is most commonly used in which healthcare setting?
physician's office
Dr. Schultz has just examined Natalia Shrier who had come to see him because she has been having increasing problems with gastroesophageal reflux. Dr. Schultz has instructed Natalia to avoid hot, spicy foods, to avoid eating within three hours of going to bed, to raise the head of her bed, and has given her an order to have an Upper GI x-ray. Dr. Schultz's instructions are part of which element in a SOAP note?
In a hospital setting, what document is the equivalent of the assessment and plan that is collected as part of a SOAP note in an outpatient record?
Discharge Summary
Alison Holt just received a copy of her Clinical Visit Summary from the visit to her primary care provider earlier in the day. She is reading that her symptoms were present for the past four days, and that she did not get any relief from Motrin. To which section of the SOAP note does this information pertain?
During the history, Kevin Goodell notes that the pain in his right hip is more of a dull pain than an ache. This is considered what part of the history of present illness (HPI)?
A patient states that her pain is an 8 on a scale of 1 to 10. This is known as the ______________ in a history of present illness (HPI).
A patient with knee pain has been using pain patches to alleviate the pain; she has been using the kind that are left on the area for several hours. Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI).
modifying factor
The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient's visit.
Neil Rabinski was asked by the care provider if he has had any difficulty breathing, shortness of breath, or noticeable wheezing. This is part of the review of systems for the __________________ system.
The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)?
constitutional (or general)
Which of the following professionals would not perform a physical examination (PE)?
medical assistant
Dr. Gaviria chooses to have someone enter findings and results into the EHR as she is examining the patient. _____________ are assistants who may enter the information.
The healthcare professional who types reports for care providers is known as a/an ______________.
Which of the following is a benefit of voice recognition?
documents are made part of the patient's record in a timelier manner
One of the reasons ePrescribing is being used by a greater number of physicians' practices is that it:
is a requirement of the HITECH Meaningful Use regulations.
A computerized system which allows physicians to request lab, radiology, or pharmacy services for their patients is known as:
computerized physician order entry
In order for any test, procedure, or medication to be administered to a patient, there must be a:
care provider's order
In order for Dr. Reynolds to send a CPOE from her office computer system to the computer system at the local hospital, a/an ____________________ must exist between the two computer systems.
Which of the following is a benefit of CPOE?
clinical decision support is possible through CPOE
If a computerized physician's order is sent to the local hospital for a blood test, and the physician's office has already been notified of the test findings, this order is:
Emily Haver is being seen by Dr. Clark today for her annual physical exam. She has been a patient of his for many years. She is currently being treated for hypertension and type 2 diabetes mellitus. In the late 1990's she was treated on several occasions for poison ivy. She has been treated since 2003 with Zoloft for mild depression. Of the following, which will not appear on Emily Haver's problem list?
poison ivy
Meaningful Use guidelines require the keeping of an up-to-date:
problem list
Dr. Clark has just documented his findings of a physical exam performed on Patti Wolfe. She was seen today for productive cough. These findings are considered what kind of findings, as they relate to the SOAP note?
Objective findings
The fact that a patient has taken an over the counter medication, and did receive relief of his pain. This is known as a/an what in relation to subjective documentation found in this patient'
modifying factor
Tiffany Randall is seen by her physician after falling off a piece of playground equipment. She has a laceration on her chin. This is part of which element of the history of present illness?
location of the injury
Kelly is being seen by her physician today, and he is asking her if she's had any increase in or unusual headaches since her last visit, whether she has any blurred vision, and whether she has seen her eye doctor in the past year. The answers to these and other questions are documented in what part of the health record?
Review of Systems (ROS)
How a patient is feeling, any current complaints or concerns, weight loss or gain, appetite, sleep patterns or difficulties, and a recap of vital signs. This information is documented in the general part of the ROS, and is also known as what?
constitutional (or general)
The extent of a physical exam will depend largely on the reason for the patient's visit, which is otherwise known as what?
chief complaint
LaRhonda Howard is seen today by Dr. Bilkins for a chief complaint of recurrent abdominal pain and loss of appetite. Robert Drew is seen today by Dr. Bilkins for a chief complaint of follow-up for his poison ivy, which he was treated for last week

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