EHR and Health Information Management Practices, Exams of Nursing

Download EHR and Health Information Management Practices and more Exams Nursing in PDF only on Docsity! NHA CEHRS CERTIFIED ELECTRONIC HEALTH RECORD SPECIALIST EXAM 2024-2025 ACTUAL CURRENTLY TESTING AND FREQUENTLY TESTED EXAM QUESTIONS WITH DETAILED ANSWERS WITH RATIONALES AND A STUDY GUIDE EXPERT VERIFIED FOR GUARANTEED PASS An EHR specialist is preparing to perform a statistical review of infection rates at a facility for quality improvement purposes. To compare statistical data with other facilities, the EHR system should be integrated with which of the following? A. Master Patient Index (MPI) B. Clinical Decision Support System (CDSS) C. Uniform Ambulatory Care Data Set (UACDS) D. Clinical encoder - ANSWER>>B. Clinical Decision Support System (CDSS) An EHR specialist is reviewing the outstanding patient account balances that were submitted to a collection agency. Which of the following documents is required to verify that the correct accounts were submitted? A. Deposit report B. Payment day sheet C. Patient ledger D. Patient aging report - ANSWER>>D. Patient aging report (The patient aging report shows how long patients have owed money) In which of the following sections should an EHR specialists locate objective findings from a patient's previous visit? A. Past medical history B. Social history C. Chief complaint D. Review of systems - ANSWER>>A. Past medical history (The past medical history section contains the objective findings from a patient's previous visit, including operations, injuries, and treatments) An EHR specialist is assisting with training on the use of the health system's EHR. A provider asks how to correct deficiencies in their documentation. Which of the following statements should the EHR specialist make? A. "Records are reviewed for completeness by the provider before they are closed during an encounter." B. "Using a template for your documentation will allow the system to produce a report that indicates required fields to complete." C. "The EHR staff conducts random charts audits and notifies providers of deficiencies by email." D. The provider will be unable to close the health record if documentation does not comply with organizational policies." - ANSWER>>B. "Using a template for your documentation will allow the system to produce a report that indicates required fields to complete." An EHR specialist is contacted by an emergency department in another state regarding an established patient who is receiving treatment. Which of the following network connections should the EHR specialist use to transmit information? A. Local area network (LAN) B. Wide area network (WAN) C. Virtual private network (VPN) D. Wireless local area network (Wi-Fi) - ANSWER>>C. Virtual private network (VPN) (VPN allows EHR users to connect securely over the internet to a facility's website by verifying their identity, users located in different states connect remotely to the network) When obtaining data from a new clinic patient, an EHR specialist should understand that which of the following statements by the patient indicates a history of present illness? A. "I had an appendectomy when I was 30." B. "My partner had pneumonia a year ago." C. I really think I need to have a chest x-ray taken." D. "I came because I've been coughing for several days." - ANSWER>>D. "I came because I've been coughing for several days." A. Data backup and storage B. Encryption C. Password management D. Automatic logoff - ANSWER>>C. Password management (Data backup and storage is example of physical safeguard while encryption and automatic safeguard are technical safeguards) An EHR specialist is assisting a records clerk with the handling of a removable media device containing protected health information (PHI). Which of the following actions should the EHR specialist tell the clerk to take to prevent a security risk? A. Place the device in an allocated area for reuse B. Discard the device in the front office trash can C. Remove protected health information from the device D. Make a copy of the information on the device to store in an office location - ANSWER>>C. Remove protected health information from the device An EHR specialist should identify that which of the following is the process for converting text into code for secure transmission? A. Entity authentication B. Data backup plan C. Integrity controls D. Encryption - ANSWER>>D. Encryption (The EHR specialist should identify that encryption converts regular text into code using a mathematical formula called an algorithm) An EHR specialist is creating template for patient demographic information. Which of the following information should be required in this section of the EHR? A. Chief complaint, diagnosis, and insurance plan B. Social history, medical history, and family history C. Height, weight, and vital signs D. Name, date of birth, and address - ANSWER>>D. Name, date of birth, and address Which of the following patient portal features meet the criteria for patient engagement as part of EHR incentive programs? A. Request my appointment B. Review medical history C. Send clinical summaries D. Get medical advice - ANSWER>>C. Send clinical summaries (Centers for Medicare and Medicaid Services (CMS) established guidelines and programs to improve patient and family engagement. The EHR specialist sending clinical summaries of current health information to providers and patients) (A CDSS should be integrated with the facility's EHR system to provide statistics and monitoring for a variety of health system functions and to identify areas for process and quality improvement) An EHR specialist is verifying if a laboratory test the provider ordered is covered under the patient's insurance contract. Which of the following steps is the EHR specialist completing? A. Preauthorization B. Precertification C. Predetermination D. Preregistration - ANSWER>>B. Precertification Which of the following forms is used to capture the diagnoses and charges related to a patient visit prior to submitting them for reimbursement? A. CMS-1500 form B. Remittance advice C. Encounter form D. UB-04 form - ANSWER>>C. Encounter form Which of the following actions should a facility take to ensure security compliance and protects EHRs from unauthorized access? A. Issue unique user identifications for use of computers B. Disable automatic logoff from computers during working hours C. Allow staff to use file-sharing applications on their mobile devices D. Deactivate remote data wiping on mobile devices - ANSWER>>A. Issue unique user identifications for use of computers An EHR specialist is assisting the provider in searching for data in a patient record. When searching for "ankle injury," no entry is identified. In additional searches, entries are located by searching "ankle sprain" and "twisted ankle." The EHR specialist should recognize that the data can be reconciled by using which of the following types of data? A. Text data B. Coded data C. Fielded data D. Digital image data - ANSWER>>B. Coded data (Standardized coded data can be instantly found and matched regardless of the provider's choice of words) Which of the following is considered protected health information? A. The patient's place of birth B. The patient's ZIP code C. The patient's diagnosis D. The patient's age - ANSWER>>C. The patient's diagnosis An EHR specialist is assisting with obtaining the history of a patient. The EHR specialist should document which of the following information in the history section of a progress note? A. Temperature B. Medication list C. Cognitive status D. Review of systems - ANSWER>>B. Medication list An EHR specialist is providing a patient with information about the patient portal. Which of the following statements by the patient indicates an understanding of the patient portal? A. "I can access my medical records without the use of a username or password." B. "I can communicate with other patients." C. I can schedule my own appointments." D. "I can update my preferred care plan." - ANSWER>>C. I can schedule my own appointments." An EHR specialist is assisting a medical assistant with entering a patient's ongoing temperature measurements into the EHR. The EHR specialist should understand that the results is documented in which of the following locations? D. The phlebotomist assigns consecutive numbers to each sample, according to the time it was obtained - ANSWER>>C. Labels are automatically printed at the point of care as part of the automatic requisition process An EHR specialist is assisting a provider to enter a clinical order to obtain three blood draws. Which of the following components of the EHR should the EHR specialist assist the provider to access? A. CDSS B. Billing C. Schedules D. CPOE - ANSWER>>D. CPOE (The EHR specialist should assist the provider to access the computerized provider order entry (CPOE) component of the EHR. The provider can use the CPOE to enter prescriptions and orders for diagnostic purposes) An EHR specialist is assisting a nurse who receives a prescription for morphine sulfate sent via the EHR system. The prescription states, "Increase MS to 2 mg IV Q4H." The EHR specialist should reconcile the information to read as which of the following statements in the patient's record? A. Morphine sulfate 2.0 mg intravenously Q4H B. MS 2 mg IV every four hours C. Morphine sulfate 2 mg IV Q4H D. MS 2 milligrams IV Q4H - ANSWER>>C. Morphine sulfate 2 mg IV Q4H (MS is a "do not use" abbreviation and must be written as morphine sulfate to match the medication name in the EHR) An EHR specialist is assisting a provider with finding codes for a dentistry procedure. Which of the following classification systems should the health record specialist use? A. CDT codes B. ICD-10-PCS codes C. CPT codes D. DSM-5 - ANSWER>>A. CDT codes (The uniqueness of dental specialty warranted the creation of the codes that reference dental procedure codes and allows the providers to bill for dental services) An EHR specialist is collaborating with a coder about reports available in the new EHR system. The EHR specialist should instruct the coder that which of the following reports shows the income generated by each third-party payer? A. Day sheet report B. Patient aging report C. Production by insurance report D. Billing/payment status report - ANSWER>>C. Production by insurance report An EHR specialist is assisting a facility in implementing a recent upgrade to the EHR system. Which of the following would be the best question for the EHR specialist to ask in preparation for implementation? A. "How many other facilities have completed the upgrade?" B. "What is the timeline for these changes?" C. "What is the facility's cost for the upgrade?" D. "What are the anticipated IT challenges of the upgrade?" - ANSWER>>B. "What is the timeline for these changes?" A provider at an inpatient facility is reviewing pending tasks and messages through the EHR's messaging feature. Which of the following tasks is most important for the provider to complete? A. Signing a history and physical for a patient admitted 36 hr ago B. Completing a referral request for a patient who submitted the request today C. Writing a history and physical note for a patient scheduled for surgery later that day D. Authentication of an order entered by the nurse during the surgery that was just completed - ANSWER>>A. Signing a history and physical for a patient admitted 36 hr ago An EHR specialist is assisting with providing training for a group of admission clerks about an EHR system. In which of the following data sections of the record should the EHR specialist instruct the group to enter a patient's HIPAA forms? A. Legal data B. Clinical data C. Financial data D. Administrative data - ANSWER>>A. Legal data Which of the following actions should a patient take to authorize a participating health care organization to receive payment from a third-party payer? A. Verbally authorize assignment of benefits to the health care organization B. Provide a signature for assignment of benefits to the health care organization C. Contact the third-party payer to assign benefits to the health care organization D. Contact an insurance agent to assign benefits to the health care organization - ANSWER>>B. Provide a signature for assignment of benefits to the health care organization An EHR specialist is preparing to enter information into a patient's record. The EHR specialist has confirmed the patient's medical record number. Which of the following patient identifiers should the EHR specialist use as a second identifier to verify the patient's identity? A. Patient's address B. Mother's maiden name C. Name of patient's nearest relative D. Name of patient's insurance provider - ANSWER>>A. Patient's address An EHR specialist reads a provider progress note stating, "Patient diagnosis: Lymphoma. Received six rounds of chemotherapy beginning June 2020. Patient reported diarrhea, loss of appetite, and fatigue with treatment. Last cycle of chemo was administered Nov. 2019; now in remission." Which of the following actions should the EHR specialist take? A. Query the provider to resolve the discrepancy B. Input the note on the physical examination form C. Contact the patient to verify dates of treatment D. Correct the dates of treatment in the patient's record - ANSWER>>A. Query the provider to resolve the discrepancy (The EHR specialist should query/question the provider to clarify the dates the patient received treatment.) An EHR specialist receives a call from the parent of an 18-year-old patient asking why their child was seen at the office last week. Which of the following actions should the EHR specialist take? A. Ask for the patient's name and date of birth and give the requested information C. Review the IT company's record filed with its state regulatory agency D. Enter into a business associates contract with the IT contractors - ANSWER>>D. Enter into a business associates contract with the IT contractors An EHR specialist is performing an internal audit of the EHR records and discovers improper billing documentation that suggests potential fraud or abuse in accounts of patients who have a private third-party payer. Which of the following agencies should handle this type of inquiry? A. Centers for Medicare and Medicaid Services (CMS) B. Office of the National Coordinators for Health Information Technology (ONC) C. Office of Inspector General (OIG) D. The Joint Commission (TJC) - ANSWER>>C. Office of Inspector General (OIG) (The specialist should notify the OIG in the U.S Department of Health and Human Services when improper documentation is discovered) An EHR specialist receives records transmitted from a hospital about an established patient's recent admission. The EHR specialist identifies potential discrepancies in the patient's past medical history. Which of the following actions should the EHR specialist take? A. Contact the hospital to update their records B. Change the EHR record to reflect the hospital's data C. Reconcile the patient's hospital record with the office record D. Request a co-worker review the records - ANSWER>>C. Reconcile the patient's hospital record with the office record Which of the following documents is received by the health care organization from the insurance carrier after a claim has been processed? A. Superbill B. Assignment of benefits C. Explanation of benefits (EOB) D. Remittance advice (RA) - ANSWER>>D. Remittance advice (RA) (An RA is a document that is sent to the provider's office and gives details of the third-party payers determination) An EHR specialist is preparing to generate a report for a supervisor that indicates the amount of revenue generated by throat cultures. Which of the following reports should the EHR specialist generate? A. Day sheet report B. Remittance advice report C. Billing/payment status report D. Production by procedure report - ANSWER>>D. Production by procedure report (A production by procedure report indicates the number of total procedures completed within a given timeframe along with the associated revenue generated by each type of procedure) An EHR specialist works in a clinic that uses patient-entered data collection. Which of the following information should the patient enter into the EHR prior to arrival for the visit with the provider? A. Recent prescription refill and pharmacy location B. The date of last office visit and chief complaint C. Current result of an MRI procedure D. Recent surgery and reason for this office visit - ANSWER>>D. Recent surgery and reason for this office visit Which of the following is required when health care facilities provide data on vaccinations to public health agencies? A. The data must refer to adult patients B. The data must be from patient who have multiple conditions C. The data must be dated and updated monthly D. The data must be anonymous and confidential - ANSWER>>D. The data must be anonymous and confidential When generating admission documentation for a patient, which of the following information should an EHR specialist enter in the legal data section of the EHR? A. List of medications B. Insurance provider C. Emergency contact D. Advance directives - ANSWER>>D. Advance directives An EHR specialist is collaborating with a clinical order to train the billing staff of a facility using a new EHR system that includes computer-assisted coding (CAC) software. Which of the following actions should the billers take when creating a claim to ensure the CAC assigned an accurate procedure code in the patient record? A. Confirm the code with the department that performed the procedure B. Validate the procedure code with documentation in the patient health record C. Request an internal coding audit be performed on the procedure code D. Send a query to the provider to confirm the procedure is coded correctly - ANSWER>>B. Validate the procedure code with documentation in the patient health record Which of the following occurs when a provider enters an imaging order while documenting in an encounter note? A. The encounter note will become part of the imaging order B. Entries in the encounter note will be added to the radiologist's interpretation of the study C. The order will generate a template for the encounter note D. The order is automatically documented in the visit - ANSWER>>D. The order is automatically documented in the visit An EHR specialist is registering a new patient. Which of the following documents should the EHR specialist ensure is signed by the patient to acknowledge their understanding of why protected health information (PHI) might be released? A. Advanced Beneficiary Notice (ABN) B. Assignment of Benefits C. Notice of Privacy Practices (NPP) D. General Consent for Treatment - ANSWER>>C. Notice of Privacy Practices (NPP) An EHR specialist is assisting with the training of a newly-hired billing specialist who asks, "What is the purpose of a billing and payment status report?" Which of the following responses should the EHR specialist make? A. "It assists with budgeting and revenue management." B. "It lists the standing of each patient's account." C. "It identifies patient information and the amount paid by the third-party payer." D. "It shows how many patients are treated in a specific period by the provider." - ANSWER>>B. "It lists the standing of each patient's account." An EHR specialist is assisting a nurse practitioner with an electronic order entry for a patient test. Which of the following statements should the EHR specialist make? A. "The provider is unable to order a test while creating an encounter note." B. "The order system is unable to display a patient's list of recent test orders." C. "The order system matches order test codes with patient insurance coverage rules." D. "After you order the test, make sure to complete the requisition form." - ANSWER>>C. "The order system matches order test codes with patient insurance coverage rules." An EHR specialist is trying to determine if "IU" is an acceptable abbreviation to use if medical documentation. Which of the following organizations provides a resource that the EHR specialist can use to verify acceptable abbreviations? A. National Committee for Quality Assurance B. Centers for Medicare and Medicaid Services C. Healthcare Information and Management Systems Society D. The Joint Commissions - ANSWER>>D. The Joint Commissions An EHR specialist is preparing to create a report that lists patients who have received a positive result on their testicular cancer screening. Which of the following type of production report should the EHR specialist create? A. By diagnosis B. By sex C. By symptom D. By provider - ANSWER>>A. By diagnosis An EHR specialist is preparing a financial report to compare the amount of reimbursement provided by different third-party payers for a specific procedure. Which of the following should the EHR specialist use to identify the procedure in question? A. CPT codes B. ICD-10-CM codes C. Past/Family/Social history (PFSH) D. Review of system (ROS) - ANSWER>>A. CPT codes An EHR specialist is educating a newly hired staff member about the security management process. Which of the following procedures should the EHR specialist indicate involves regularly reviewing records, access reports, and security incident tracking reports? A. Sanction policy B. Information system activity review C. Risk management D. Risk analysis - ANSWER>>B. Information system activity review (The information system activity review involves regularly reviewing records, access reports, and security incident tracking reports to identify if protected health information has been disclosed or used inappropriately.) An EHR specialist is developing templates for an acute care facility's EHR database. The EHR specialist has received a request to enter a template for recording patient hemoglobin levels. Which of the following sections of the EHR should the template be entered? A. Pathology B. Laboratory C. Demographics D. Diagnostic imaging - ANSWER>>B. Laboratory An EHR specialist scans an image to a patient's medical record prior to the patient's scheduled appointment using the office scanner connected to the desktop computer by USB cable. At the appointment, the provider is unable to find the image for review. Which of the following is the likely cause? A. Scanned documents are routed, in random order, to a single tab in the EHR B. There was a decryption error in document transmission C. The image was incorrectly catalogued D. It was not electronically signed by the EHR specialist - ANSWER>>C. The image was incorrectly catalogued An EHR specialist is assisting a registered nurse with discharging a patient who has difficulty adhering to the medication regimen. Which of the following statements should the EHR specialist make about accessing disease-specific education materials? A. "Our EHR system sends out general health tips. May I have your mobile phone number?" B. "The patient portal has lots of helpful information. I will show you how to access information about your medication." C. "Be sure to review your clinical summary. You should receive it in a few days." D. "There are many helpful websites about medication. When you search, be sure to look for sites that are reputable." - ANSWER>>B. "The patient portal has lots of helpful information. I will show you how to access information about your medication." Which of the following is an example of a data backup method that is HIPAA-compliant and allows for the recovery of data following a natural disaster? A. Maintaining servers that are off site in a different region B. Storing data on a unencrypted thumb drive C. Emailing data to a personal email account D. Using tape backups that are stored 25 miles from the office - ANSWER>>A. Maintaining servers that are off site in a different region An EHR specialist is accessing the EHR system through a computer workstation. Which of the following are required components of a computer workstation? A. A computer, an input device, and an output device B. A computer tower, a monitor, and a telephone C. Electronic equipment, a chair, and telemonitors D. A mobile device, charging hardware, and an internet modem - ANSWER>>A. A computer, an input device, and an output device Which of the following is an example of a technical safeguard? A. Assignments of security responsibilities B. Off-site computer backups C. Authentication controls on computers D. Protection against environmental hazards - ANSWER>>C. Authentication controls on computers (Off-site computer backups & Protection against environmental hazards are physical safeguards; security responsibility assignments are administrative safeguards) An EHR specialist is assisting with check-out of a patient. The patient says, "I hope I can remember everything about this new medication." Which of the following responses should an EHR specialist make? A. "We will ensure that the patient who was recently diagnosed with stage II colon cancer is prescribed this medication." B. "One of our patients who has gastric esophageal reflux disease and is taking ranitidine cannot afford to pay for the new medication." C. "Mr. F. Jones, who is a patient in one of our Atlanta facilities, could benefit a lot from the medication." D. "Our facility has a patient who is indigent and has stomach problems who could benefit from this medication." - ANSWER>>D. "Our facility has a patient who is indigent and has stomach problems who could benefit from this medication." An EHR specialist receives a phone call from an established patient who has multiple chronic conditions. The patient thinks they might have pneumonia and would like to know if it would affect any of their chronic conditions. In which of the following sections of the patient's record would the chronic conditions be located? A. Chief complaint B. Problem list C. Social history D. Physical exam - ANSWER>>B. Problem list (The problem list provides a current list of any of the patient's diagnosed conditions that is maintained from visit to visit) An EHR specialist is assisting with providing user training to staff members regarding an upgrade to the EHR system. Which of the following statements should the EHR specialist make when asked about a way to help minimize the number of patients who miss their scheduled appointments? A. "The patient should be billed for any missed appointments." B. "The system will automatically reschedule the missed appointment." C. "You should send the patient a text message reminder of the appointment." D. "An automated confirmation of appointments may be set in the EHR system." - ANSWER>>D. "An automated confirmation of appointments may be set in the EHR system." Which of the following types of data are considered structured data in the EHR? A. ICD codes B. Progress notes C. Operative reports D. Test interpretations - ANSWER>>A. ICD codes A patient presents to the emergency department and states, "I have terrible chest pain." An EHR specialist should document this information in which section of the EHR? A. Past/Family/Social history B. Chief complaint C. Review of systems D. Physical examination - ANSWER>>B. Chief complaint An EHR specialist is preparing to obtain information about patient outcomes by individual provider for quality improvement. Which of the following actions should the EHR specialist take to collect the necessary information? A. Contact The Joint Commissions (TJC) to access the patient data for individual providers. B. Generate electronic clinical reports using patient records from the EHR. C. Request information from the National Quality Measures Clearinghouse (NQMC). D. Meet with individual providers within the practice to obtain patient data. - ANSWER>>B. Generate electronic clinical reports using patient records from the EHR. A medical practice uses a different electronic billing system than the one built into the EHR. Which of the following methods should the practice's billing system and the EHR use to exchange information? A. Manual entry of paper correspondence B. An interface C. Downloading and uploading information from external drives D. A USB connection - ANSWER>>B. An interface Which of the following describes the process of claim scrubbing? A. Adjusting billing to account for costs in specific geographic areas B. Accepting electronic claims from providers C Categorizing services as medical, surgical, or nonsurgical D. Checking claims for any errors - ANSWER>>D. Checking claims for any errors An EHR specialist is discussing hardware costs with the department controller. Which of the following statements by the department controller describes the advantage of purchasing server hardware for a local area network (LAN)? A. "Dedicated servers for a LAN will minimize hardware costs." B. "Dedicated servers for a LAN simplify connectivity because they require wired connections." C. "Dedicated servers for a LAN ensure secure, safe exchange of data between workstations." D. "Dedicated servers for a LAN provide connectivity over a wide geographic area." - ANSWER>>C. "Dedicated servers for a LAN ensure secure, safe exchange of data between workstations." Which of the following information must be recorded in the guarantor section of the registration form if the patient's spouse is the guarantor of the account?*** A. The patient's name, birth name, and phone number B. The spouse's name, address, and phone number C. The address and phone number of the insurance company D. The patient's signature for assignment of benefits - ANSWER>>B. The spouse's name, address, and phone number (The guarantor is responsible for payments that are not covered by the insurance company; therefore, only the spouse's name, address, and phone number should be entered in the guarantor section.) An EHR specialist is assisting the billing department and researching a claim for a patient who has Medicare and had a procedure that was not covered by the plan. Which of the following should the EHR specialist verify was completed prior to billing the patient? A. Patient day sheet B. Remittance advice report C. Advanced beneficiary notice D. Explanation of benefits form - ANSWER>>C. Advanced beneficiary notice (An advanced beneficiary notice (ABN) is a waiver of liability that indicates a service is not covered by Medicare and is the patient's financial responsibility. The EHR specialist should check for an ABN prior to billing a patient) Which of the following patient identifiers should the EHR specialist verify before documentation is entered into an EHR? A. Patient's room number B. Patient's provider name C. Patient's medical diagnosis Which of the following patient information entered and verified during admission to the facility will likely generate an alert to the provider when using the computerized provider order entry system (CPOE)? A. Known medication allergies B. Last surgical procedure C. Immunization history D. Family medical history - ANSWER>>A. Known medication allergies Which of the following methods can patients use to enter data into the record themselves? A. Email B. Check-in kiosk C. Telephone D. Mail - ANSWER>>B. Check-in kiosk An EHR specialist is assisting the unit staff during a go-live session for implementation of the EHR system. The EHR specialist overhears a nursing assistant stating to another staff member, "I forgot my password. Can you log in so I can chart this information right now?" Which of the following actions should the EHR specialist take? A. Report the incident to another staff member B. Help the nursing assistant obtain a new password C. Document the information for the nursing assistant D. Ignore the private conversation regarding a password - ANSWER>>B. Help the nursing assistant obtain a new password An EHR specialist is organizing an in-service for staff members about securing personal mobile devices for work-related use. Which of the following instructions should the EHR specialist include? A. Enable file-sharing applications B. Disable built-in encryption systems C. Enable a firewall D. Disable remote wiping for devices - ANSWER>>C. Enable a firewall Which of the following is an EHR documentation tool that a provider can use to add comments for increasing the specificity of a physical examination finding? A. General consent B. Lists C. Action buttons D. Free-text boxes - ANSWER>>D. Free-text boxes A billing specialist is preparing to electronically submit charges to a patient's third-party payer for a completed procedure. Which of the following actions should the billing specialist perform before applying the charges to the patient's account? A. Review the charges to verify documentation in the patient's record B. Ensure a paper encounter form was completed to verify the charges C. Confirm that the internal coding audit has reviewed the bill for accuracy D. Verify the patient's insurance to ensure billing accuracy - ANSWER>>A. Review the charges to verify documentation in the patient's record How frequently should a health care organization obtain permission from a patient to release protected health information (PHI) for processing insurance claims? A. Each calendar year B. Every fiscal year C. Once D. Every visit - ANSWER>>C. Once An EHR specialist must comply with the requirements of an EHR incentive program. Which of the following data is the EHR specialist required to submit to public health agencies? A. Documented allergies B. Reportable laboratory results C. Prescribed and over-the-counter medications D. Medical history - ANSWER>>B. Reportable laboratory results (Measles, rubella, and anthrax are all reportable examples.) When attempting to enter an electronic order, a provider enters a term into the search box, and then asks an EHR specialist for assistance in locating information more specific to the term. Which of the following statements should the EHR specialist make? A. "The system prevents more than one word at a time to be searched." B. "Searching will display the lowest level match of the word entered." C. "Expand the search to the next level." D. "Entering a word in the search window will display every entry containing that word." - ANSWER>>C. "Expand the search to the next level." An EHR specialist receives a written prescription that has not been entered into the e-prescribe feature of the EHR. The EHR specialist should understand which of the following facts about submitting prescriptions electronically A. E-prescribing helps to decrease medication errors B. E-prescribing allows for more accurate CPT coding C. E-prescribing is required by the HIPAA Privacy Rule D. E-prescribing increases health care costs for patients - ANSWER>>A. E-prescribing helps to decrease medication errors An EHR specialist is generating patient statements. Which of the following types of information will be included? A. Date of service B. Marital status C. Prescriptions D. Chief complaint - ANSWER>>A. Date of service A provider requests an EHR specialist to gather information on the practice's patient procedure to monitor outcomes for patients who have diabetes mellitus. Which of the following actions by the EHR specialist would be most efficient? A. Generate an electronic clinical report about the information B. Telephone involved patients to inquire about their progress C. Collaborate with other providers in the practice to determine the information D. Check with pharmacies regarding patient compliance with medication regimen - ANSWER>>A. Generate an electronic clinical report about the information An EHR specialist is reviewing the record of a patient who is in a coma. Which of the following entries documented in the record signals a data discrepancy? A. "The patient's head is elevated." B. "The patient's partner is present." C. "The patient reports a headache." C. Chief complaint D. Treatment plan - ANSWER>>B. Diagnosis code A provider is caring for a patient who has Dengue fever. The provider has not encountered this diagnosis for several years. Which of the following tools will assist the provider in determining the current treatment for this condition? A. Clinical decision support system B. International Classification of Diseases (ICD-10-CM) C. Master patient index D. Data registry - ANSWER>>A. Clinical decision support system (The Clinical decision support system (CDSS) is a tool in the EHR system that provides access to clinical information, including current treatments) An EHR specialist at a large health care facility is working with a provider who asks why front desk personnel cannot help with workflow by opening and forwarding laboratory results to consulting specialists. Which of the following responses should the EHR specialist make? A. "The front desk personnel user permissions do not allow forwarding of patient results." B. "The front desk personnel training does not include forwarding patient results." C. "The EHR software does not include this function." D. "The front desk personnel's professional organization prohibits them from handling patient results." - ANSWER>>A. "The front desk personnel user permissions do not allow forwarding of patient results." Before running an electronic report, a staff member seeks clarification from the EHR specialist by asking, "What is the purpose of the patient aging report?" Which of the following statements should the EHR specialist make? A. "It shows the current age of individual patients in the practice." B. "It shows how long patients have owed money to the practice." C. "It shows how long patients have been treated by the practice." D. "It shows the ages of death of patients who were treated by the practice." - ANSWER>>B. "It shows how long patients have owed money to the practice." An EHR specialist is assisting a certified coder with providing an in-service about the purpose of Current Procedural Terminology (CPT) codes for a group of staff members. Which of the following staff member statements indicates an understanding of the teaching? A. "CPT codes are used to classify services provided to patients." B. "CPT codes group patients using demographic information." C. "CPT codes are used to classify patient diagnoses." D. "CPT codes are different from one facility to the next." - ANSWER>>A. "CPT codes are used to classify services provided to patients." Which of the following is the most important characteristic of the digital images produced by a scanner? A. Digital images require a human to view and interpret them. B. The digital images can be translated into text from the scanner. C. Digital images are the most common way to store data in the EHR. D. EHR systems can instantly find the data that the digital images contain. - ANSWER>>A. Digital images require a human to view and interpret them. A patient who was discharged from the hospital yesterday telephones to ask how to view their final laboratory results. Which of the following EHR components should the EHR specialist instruct the patient to access? A. Personal health record (PHR) B. Clinical decision support system (CDSS) C. Patient portal D. Practice management system - ANSWER>>C. Patient portal When recording information in a patient's health record, an EHR specialist should understand that the consent forms represent which category of data in the EHR? A. Administrative data B. Clinical data C. Financial data D. Legal data - ANSWER>>D. Legal data Which of the following types of data exchanged between a health care facility and its diagnostic laboratory can generate a visual representation of trends in a patient's laboratory results over time? A. Fielded and coded data B. Text data C. Digital document image data D. Patient-entered data - ANSWER>>A. Fielded and coded data An EHR specialist is entering data in the record of a pediatric patient whose parent calls the office to report the child is experiencing hives when taking amoxicillin for the first time. In which of the following locations in the record would the EHR specialist find information about the child's prior reaction to medications? A. The assessment section B. The allergy section C. The computerized provider order entry (CPOE) D. The medical reference screen - ANSWER>>B. The allergy section An EHR specialist is assisting with training about an event of unexpected downtime of the EHR. Which of the following statements from a staff member indicates an understanding about submitting claims during a downtime procedure? A. "I can wait for the system to recover before submitting a claim." B. "I can submit a paper claim during downtime." C. "I can access claims via a web-based system during downtime." D. "I can access claims from the on-site server during downtime." - ANSWER>>B. "I can submit a paper claim during downtime." Which of the following methods should an EHR specialist implement to ensure that providers who are logged into the system from their mobile devices are authorized to access protected health information (PHI)? A. Require all clinicians logging in from mobile devices to encrypt their passwords. B. Require an end-user who is logging in from a mobile device to have a personal identification number (PIN). C. Implement audit control to authenticate each user who logs into the EHR from a mobile device D. Install a file-sharing application to ensure all connected devices are secure. - ANSWER>>B. Require an end-user who is logging in from a mobile device to have a personal identification number (PIN). Which of the following situations demonstrates appropriate documentation of data entered by the provider during an inpatient facility stay? A. The provider completes a history and physical (H&P) examination within 24 hr after admission. A. This abbreviation is unacceptable to The Joint Commissions (TJC) B. This abbreviation will be added to the organization's list of standard abbreviations C. The provider should refrain from using any abbreviations when documenting a discharge summary D. The provider's documentation complies with American Hospital Association regulations. - ANSWER>>C. The provider should refrain from using any abbreviations when documenting a discharge summary An EHR specialist is scanning a patient's x-ray results into the EHR. The EHR specialist should recognize that the EHR is fulfilling which of the following core functions laid out by the Institute of Medicine (IOM) by supporting this type of information? A. Health information and data B. Order management C. Patient support D. Administrative processes and reporting - ANSWER>>A. Health information and data (The Health information and data function of the EHR allows for entering and displaying patient information such as progress notes, test results, and other general diagnostic information, including scanned documents and images.) During an orientation, a new coder states, "There is no need for the coder to review both the superbill and the health record documentation." Which of the following responses should the EHR specialist make? A. "Ask the provider whether you should use the superbill over the health record." B. "Verify the superbill against the health record documentation." C. "The provider's documentation is the only source the coder is required to review." D. The superbill is the only source the coder is required to review." - ANSWER>>B. "Verify the superbill against the health record documentation." Which of the following is the most important factor in compiling data for reports to the Medicare Merit-Based Incentive Payment System (MIPS)? A. Selecting an appropriate dictation software system B. Timely submission of accounting reports C. Accuracy of clinical documentation D. Interoperability with Medicare system - ANSWER>>C. Accuracy of clinical documentation An EHR specialist is sending patient data that includes PHI to be used for research to the local health care facility. Which of the following data must be de-identified? A. Laboratory work request B. List of physical therapy services provided within a 24-hr period C. List of radiology services provided over the last 30 days D. Production by provider report - ANSWER>>A. Laboratory work request A provider requests that an EHR specialist enter a comorbidity of depression into the EHR to allow the provider to complete a medication order for the clinic visit. A comorbidity should be entered into which of the following sections of the record? A. Primary diagnosis B. Secondary diagnosis C. Probable diagnosis D. Admission diagnosis - ANSWER>>B. Secondary diagnosis An EHR specialist receives a request to generate a report with fields including claims that need to be billed or rebilled by the patient. The EHR specialist should generate which of the following reports? A. Deposit report B. Day sheet report C. Remittance advice report D. Billing/payment status report - ANSWER>>D. Billing/payment status report An EHR specialist is assisting with providing training to a newly hired provider. Which of the following statements should the EHR specialist make regarding the e-prescribing feature of the EHR? A. "The e-prescription is copied to a secure email to be transmitted to the pharmacy." B. "The pharmacist enters the e-prescription into the EHR." C. "A renewal authorization can be transmitted using this feature." D. "The receptionist can use e-prescriptions to reorder expired medications." - ANSWER>>C. "A renewal authorization can be transmitted using this feature." (One feature of e-prescribing is the ability to renew authorization of a medication.) An EHR specialist is training new front desk staff about sending referral records securely. A staff member asks, "What if I get called away while working on a record and forget to close the chart?" Which of the following responses should the EHR specialist make? A. "You'd better not do that. You will be let go because that is a violation of patient confidentiality." B. "Nobody will see it. Only employees are allowed to be back at the desk." C. "It has a security feature. If you step away for a couple of minutes, it will log you out automatically." D. "The system tracks everything you do. If you leave your workstation too much, you'll have to repeat some training." - ANSWER>>C. "It has a security feature. If you step away for a couple of minutes, it will log you out automatically." Insurance verification takes place in which of the following phases of the revenue cycle? A. After receiving the remittance advice B. When submitting the claim C. During the encounter D. Preregistration - ANSWER>>D. Preregistration A medical office manager is considering methods for improving the process of reviewing radiology reports that are manually entered into the EHR as a progress note. Which of the following processes should the EHR specialist suggest as being most efficient? A. Printing and scanning reports into the EHR with concurrent provider alert B. Sending reports to providers by email for review and uploading to the EHR C. Importing reports to the EHR with concurrent provider alert D. Sending reports to the office nurse for uploading and forwarding to provider inbox - ANSWER>>C. Importing reports to the EHR with concurrent provider alert (This process is most efficient because it enters the report into the EHR in one step, requires review and handling by one staff member, and allows the provider to view it remotely with handheld devices. such as laptops and smart phones.) An EHR specialist is reviewing the record of a patient who is 2 days postoperative following a left hip arthroplasty. Which of the following entries documented in the record signals a data discrepancy? A. Patient's partner is visiting Which of the following reports should an EHR specialist create for a practice manager to provide information for assisting in the scheduling of staff? A. Day sheet report B. Remittance advice report C. Billing/payment status report D. Production by provider report - ANSWER>>D. Production by provider report (One of the benefits of the production by provider report is the ability to track statistics over time to assist with staff scheduling.) A patient who has Medicare Part B needs dentures that costs $1,500.00. What percentage of the total cost will the patient be responsible for paying? A. 0% B. 20% C. 25% D. 100% - ANSWER>>D. 100% (The patient should expect to pay the entire amount for dentures because they are a noncovered service under Medicare Part B.) In which of the following locations of the EHR system should an EHR specialist find documentation about a patient whose cultured sputum tested positive for methicillin-resistant Staphylococcus aureus (MRSA)? A. The respiratory subsection of the review of systems (ROS) B. The laboratory section C. The pathology section D. The respiratory exam subsection of the physical examination - ANSWER>>B. The laboratory section Which of the following is a computer protocol that specifically supports both clinical and administrative health data? A. Digital Imaging and Communications in Medicine (DICOM) B. Health Level 7 (HL7) C. Clinical data Interchange Standards Consortium (CDISC) D. National Council for Prescription Drug Program (NCPDP) - ANSWER>>B. Health Level 7 (HL7) (HL7 is the standard and protocol used for transmitting both clinical and administrative data. This includes patient care information, demographic data, and financial information.) In which of the following situations should an EHR specialist use a trend analysis report? A. When organizing data across a health care institution B. When representing data in numerical proportions C. When comparing data across dates and events D. When using data to monitor progress - ANSWER>>C. When comparing data across dates and events Which of the following information documented by a provider during a patient's visit should be included on the electronic superbill? A. patient's past medical history B. Laboratory tests C. Diagnosis codes D. SOAP notes - ANSWER>>C. Diagnosis codes A patient arrives at an initial health care visit for an occupational injury covered under workers' compensation plans. An administrative professional collects proof of identity and demographic information. Which of the following additional documentations should the administrative professional request? A. A consent to release form B. A medical service order C. A Doctor's First Report of Occupational Injury or Illness D. A progress report - ANSWER>>B. A medical service order An EHR specialist is assisting a new billing specialist with entering diagnosis codes for reimbursement purposes. While entering the codes, which of the following statements made by the billing specialist should the EHR specialist identify as being correct? A. "The comorbidity is entered as the primary diagnosis code." B. "It is not allowed to use a diagnosis code from a past patient visit." C. "The primary diagnosis is the reason the patient came to the hospital." D. "A condition existing concurrently with the primary diagnosis should not be billed." - ANSWER>>C. "The primary diagnosis is the reason the patient came to the hospital." A neighbor of an EHR specialist is admitted to the facility where the EHR specialist works. Which of the following HIPAA standards monitors control for accessing the neighbor's PHI without purpose for treatment, payment, and health care operations? A. Administrative safeguards B. Physical safeguards C. Technical safeguards D. Permitted disclosures - ANSWER>>C. Technical safeguards A facility staff member asks an EHR specialist what to do if a visitor requests an adult patient's health information. Under which of the following circumstances would the information be released to a visitor? A. Information should only be released to a family member B. Information should only be released verbally C. Only de-identified information should be released to the visitor D. Information should only be released with specific patient authorization - ANSWER>>D. Information should only be released with specific patient authorization An EHR specialist is working with an office manager to increase the efficiency of a health care organization. Which of the following should the EHR specialist understand is part of a successful overlapping schedule? A. Asking the patient for insurance information B. Inquiring about patient history C. Defining roles within the office D. Determining the type of appointment - ANSWER>>D. Determining the type of appointment An EHR specialist is assisting a provider with documenting data obtained during a patient's history and physical examination (H&P). Which of the following information should be included in the history section of the H&P? A. Benign colon polyps B. Laceration on right wrist C. Respiratory rate D. Disoriented to time - ANSWER>>A. Benign colon polyps (This data set is used for registration in provider offices and outpatient clinics) An EHR specialist is developing a template for capturing authorization for a researcher to use protected health information (PHI). Which of the following fields is required on the research authorization template? A. Clinical trial design details B. The research study outcomes C. The expiration date D. To whom the information can be disclosed - ANSWER>>D. To whom the information can be disclosed A health care organization has added encoding software to its EHR. How does this affect the process for internal audits? A. Internal audits should be conducted to ensure that all procedures are coded correctly B. Coding can be excluded from internal audits after the software is installed. C. Internal audits can be eliminated by the use of code assist software D. Internal audits can be delegated to clinical personnel after code is implemented - ANSWER>>A. Internal audits should be conducted to ensure that all procedures are coded correctly An EHR specialist is assisting a patient who wants to access the patient education material for assistance in smoking cessation. Which of the following documents are accessible in the patient education area of the patient portal? A. Progress notes from previous visits B. Radiology report C. Scheduling for smoking cessation classes D. Information from the American Cancer Society - ANSWER>>D. Information from the American Cancer Society An EHR specialist is importing transcribed encounter notes that the provider dictated the previous day. In which of the following data formats would these notes be saved ? A. Digital images B. Coded data C. Fielded data D. Text files - ANSWER>>D. Text files Which of the following actions by an EHR specialist exhibits professional standards of care as it pertains to the HIPAA Privacy Rule? A. Sharing clinical information between coworkers in a public area B. Accessing an 18-year old patient's information for their parent C. Disclosing a patient's clinical information following a court order D. Printing clinical information for the patient's friend - ANSWER>>C. Disclosing a patient's clinical information following a court order An EHR specialist is explaining to a new provider the process for entering a new prescription for a patient discharge. In which of the following EHR locations should the EHR specialist direct the provider to enter the information? A. Progress note B. Clinical results reporting C. E-prescribing D. Medication administration - ANSWER>>C. E-prescribing An EHR specialist is assisting the nursing assistant in entering a blood glucose bedside- monitoring result for a patient who has diabetes into the health record. The EHR specialist should understand the result is documented on which of the following sections of the record? A. Flow sheet B. Computerized provider order entry (CPOE) C. Subjective data D. Family history - ANSWER>>A. Flow sheet An EHR specialist is training a new staff member about release of information (ROI). In which of the following scenarios would an accounting of disclosures log be used? A. When the patient requests a copy of their medical records B. When the third-party payer is billed C. When a workers' compensation insurer requests records of an injured worker D. When a patient overhears a private conversation between two providers - ANSWER>>C. When a workers' compensation insurer requests records of an injured worker A patient asks an EHR specialist to provide them with a statement that shows their appointment dates and detailed charges. Which of the following documents should the EHR specialist provide to the patient? A. Itemized statement B. Remittance advice C. Payment plan D. Fee schedule - ANSWER>>A. Itemized statement When recording data in the patient record, an EHR specialist should enter the patient's history and physical in which of the following sections of the EHR? A. Legal data B. Clinical data C. Financial data D. Administrative data - ANSWER>>B. Clinical data A social worker has completed advance directives with a patient and asks the EHR specialist to enter the document into the health record. The EHR specialist should understand that advance directives are entered into which of the following sections of the health record? A. Legal data B. Clinical data C. Financial data D. Administrative data - ANSWER>>A. Legal data