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EHR Final Review Exam 2025–2026 Accurate Real Exam
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Which of the following is true of the advance payment ACO model? - answer>>>It is an incentive model.
Depending on the terms of a patient's insurance coverage, the balance remaining after insurance has paid may be: - answer>>>written off as paid in full or sent to collections.
Expected methods of payment are discussed when a patient: - answer>>>makes an appointment
The law which strengthened HIPAA privacy and security regulations was: - answer>>>Health Information Technology for Economic and Clinical Health Act (HITECH)
HIPAA defines a patient's name, social security number, employer, or medical record/account numbers that tie information to a particular person as: - answer>>>protected health information
Keeping health information to oneself is known as protecting: - answer>>>confidentiality
Blocking access to a facility's computer systems by unauthorized users is accomplished through use of - answer>>>a firewall
Nancy Jackson is the office manager of a medical practice. Each month she reviews a report that shows which staff members viewed, edited, or deleted data on a random selection of patient's records, and whether or not the
access or the actions taken were justified. Nancy is performing which function? - answer>>>auditing
In 2004, the ______________, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology organized the Certification Commission for Health Information Technology. - answer>>>American Health Information Management Association
An employee at Memorial Medical Practice released the diagnosis of a patient to the patient's spouse without an authorization. This is known as a/an - answer>>>breach of confidentiality
Lisa Haver is a patient of Dr. Randolph's. You have just opened today's mail and opened a letter from Ms. Haver's attorney because she is involved in a lawsuit regarding an auto accident. What will you do? - answer>>>look for a signed authorization in the envelope which authorizes the office to release Lisa Haver's records to the attorney
You are the office manager of Greensburg Medical Center. You have received a letter from one of your patients, Ida Healthway, asking to know the names of all employees and care providers who have accessed her EHR within the last year, since she believes someone has been spreading information about her in the community. You will provide Ms. Healthway with this information, which is known as:
a patient list - answer>>>accounting of information disclosures
Some states have a Health Information __________________, funded through the ONC, which allows the sharing of health information for continuity of care purposes - answer>>>Exchange
allergies. This core objective is the: - answer>>>ability to provide an electronic copy of health information
The presence of many conditions which pose a threat to public health must be submitted in accordance with applicable law. The ability to do so electronically would satisfy which menu objective? - answer>>>syndromatic surveillance
Greensburg Medical Center provides each patient with written documentation that details the signs, symptoms, current treatment options, and other pertinent information about their condition(s). This satisfies which menu objective? - answer>>>patient education
Some managed care plans encourage the use of clinical decision support (CDS) functionality by: - answer>>>offering monetary incentives for care providers who utilize CDS
A/an ___________________ report shows a summary but no details. - answer>>>aggregate
Danielle ran a report of congestive heart failure patients. The report includes the patients' medical record numbers, age, admission and discharge dates, and attending physician. What type of report is this? - answer>>>detail
Michelle has just come across state statistics regarding the average length of stay in acute, short term hospitals for appendectomy patients. She runs a report of patients having undergone an appendectomy in the past year at her hospital so she can compare her hospital's average length of stay to that of other hospitals in the state. What is Michelle doing? - answer>>>benchmarking
A local newspaper reporter has contacted your office requesting the total number of patients in the practice who have a diagnosis of Lyme disease, broken into the following age ranges: newborn to 18 years old, 19 to 50 years old, and 51 and older, and by zip code. To answer this inquiry, the office manager will: - answer>>>run a custom report
Patti Wolfe, a coding supervisor at the local hospital, is auditing the quality of ICD-10-CM coding. She may start by running a ____________ index to scan for obvious inaccuracies. - answer>>>disease
Robyn Malone needs to determine the total number of patients assigned to each care provider for a report to Blue Shield. She will run a _________________ index. - answer>>>physician (provider)
Some care providers enter into an agreement with managed care plans whereby the provider agrees to provide medical services to plan enrollees at a pre-negotiated rate. The providers are considered to be: - answer>>>in- network
A voluntary, pay-for-performance incentive program which care providers can participate in through the federal government is the: - answer>>>Physician Quality Reporting Initiative
Reporting cases of fraud and abuse must be made to the: - answer>>>Healthcare Integrity and Protection Data Bank
You have just entered data into an online form. The box in which you enter information is known as - answer>>>field
Every form should include the____ so that the form's use is obvious. - answer>>>Form name
Kait Simmons is a nurse at Memorial Hospital. She has just entered this note on her patient, Alex Phillips, 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. - answer>>>Unstructured
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 at the - answer>>>history and physical
The results of a patient's rapid strep test would be found in what area of a SOAP note? - answer>>>Objective
The SOAP documentation format is most commonly used in which healthcare setting? - answer>>>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? - answer>>>Plan
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? - answer>>>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 - answer>>>Subjective
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)? - answer>>>quality
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) - answer>>>severity
A patient with a 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) - answer>>>modifying factors
The review of systems (ROS) is documented for a patient care purpose and also factors into the ______ for the patient's vist. - answer>>>Charges
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. - answer>>>respiratory
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 - answer>>>constitutional
Which of the following professionals would not perform a physical examination - answer>>>medical assistant
Which of the following is a benefit of CPOE? - answer>>>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: - answer>>>returned
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? - answer>>>poison ivy
Meaningful Use guidelines require the keeping of an up-to-date: - answer>>>problem list
Of the following, which is not an element of the history of present illness (HPI)? - answer>>>quantity
n PrimeSUITE, as with many other electronic health record systems, 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: - answer>>>orders tracking
The information contained in the encounter form is eventually transferred to the ________ form for submission. - answer>>>claim
Only services deemed medically ________ can be billed to insurance. - answer>>>necessary
Charges begin to accrue once the - answer>>>MA or care provider interacts with patient
A remittance advice is typically given to a/an ________ , whereas an explanation of benefits is typically given to a/an ________. - answer>>>provider; patient
In PrimeSUITE, a red "X" on a Superbill summary indicates: - answer>>>an invalid code assignment.
To avoid negative consequences, a compliance plan should be ____ in every hospital and medical office. - answer>>>followed
The ________ is usually the person to set up information libraries within Practice Management software programs. - answer>>>office manager
To check if a claim has been paid, which menu will the healthcare professional look at? - answer>>>Accounts receivable
