NHA CEHRS EXAM 2025 NEWEST ACTUAL EXAM 200 QUESTIONS AND DETAILED CORRECT ANSWERS, Exams of Nursing

Download NHA CEHRS EXAM 2025 NEWEST ACTUAL EXAM 200 QUESTIONS AND DETAILED CORRECT ANSWERS and more Exams Nursing in PDF only on Docsity! NHA CEHRS EXAM NEWEST ACTUAL EXAM 200 QUESTIONS AND DETAILED CORRECT ANSWERS (VERIFIED ANSWERS) | 2024-2025 CERTIFIED ELECTRONIC HEALTH RECORDS SPECIALIST 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 Correct 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 Correct 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 Correct 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 Correct 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) (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 Correct 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 Correct 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." Correct 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? A. Review of systems B. Flow sheet C. Progress note D. Encounter note Correct Answer B. Flow sheet An EHR specialist should identify that which of the following members of the health care system can be granted remote access to EHRs? A. Provider B. Phlebotomy technician C. Medical assistant D. EKG technician Correct Answer A. Provider An EHR specialist is assisting a clinic nurse with data entry related to a well-baby check-up. When entering the infant's weight into the record, the EHR specialist should understand that the data would result in which of the following types of documentation? A. Assessment B. Growth chart C. Superbill D. Review of systems Correct Answer B. Growth chart Which of the following security management processes is performed first by a covered entity to determine threats to the confidentiality, integrity, and availability of protected health information (PHI)? A. Risk management B. Sanction policy C. Risk analysis D. Information system activity review Correct Answer C. Risk analysis An EHR specialist is updating patient information in the electronic health record (EHR). Which of the following is an example of administrative data that can be found in the EHR? A. Imaging test results B. Demographic information C. Surgical reports D. Immunization reports Correct Answer B. Demographic information Which of the following patient laboratory findings should be automatically forwarded to the state public health agency? policies." Correct 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) Correct 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." Correct Answer D. "I came because I've been coughing for several days." An EHR specialist is instructing the parent of a pediatric patient about the patient education feature in the patient portal. The parent asks, "How do I send this information to my child's step-parent?" Which of the following actions should the EHR specialist take? A. Ask about custody rights and mention setting limits on who can access the child's information B. Talk about best practices related to sending information securely C. Demonstrate how to send information from the patient portal. D. Guide the parent through the process of completing authorization to release medical records. Correct Answer C. Demonstrate how to send information from the patient portal. An EHR specialist is developing a template to create authorization for the health clinic to send immunization records for college-bound patients to their respective universities. To remain compliant with the Privacy rule, the EHR specialist should understand that which of the following items is required to be on the template? A. Date signed B. Time signed C. Date of birth D. Clinic address Correct Answer A. Date signed (The Privacy Rule requires the authorization contain the date signed, expiration date, to whom information is to be disclosed, what information may be disclosed, and for what purposes the information may be used.) An EHR specialist is documenting clinical data for a patient who was recently seen in an urgent care facility following a leg injury. In which of the following locations should the EHR specialist document this information? A. Clinical plan B. Patient's current medications C. Clinical flow sheet D. Problem list Correct Answer D. Problem list A medical office receives an imaging report via fax machine and an EHR specialist scans it into the patient's record. This is an example of which of the following methods of data collection? A. Manual B. Interfacing C. Automated D. Interoperable Correct Answer A. Manual (When a staff member is required to transfer data from an outside source to the medical record, this is called manual data entry.) A. The specimens are delivered to the laboratory, where the labels will be generated when the laboratory personnel change their status to "received." B. The phlebotomist writes three unique patient identifiers on the specimen container immediately after specimen collection C. Labels are automatically printed at the point of care as part of the automatic requisition process D. The phlebotomist assigns consecutive numbers to each sample, according to the time it was obtained Correct 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 Correct 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 Correct 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 Correct 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 Correct 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?" Correct 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? D. Correct the dates of treatment in the patient's record Correct 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 B. Check the patient's medical record for a release of information form to determine if the parent is listed. C. Notify the patient's provider to get permission to give the requested information to the parent D. Suggest the parent attend the patient's next scheduled visit in 2 weeks and ask any questions at that time Correct Answer B. Check the patient's medical record for a release of information form to determine if the parent is listed. Which of the following methods should an EHR specialist use to make changes or corrections to entries in the EHR? A. Write an addendum to the existing entry B. Delete the original entry and insert a new entry C. Reopen the encounter and change the original entry D. Contact the health information management team to request access for a correction Correct Answer A. Write an addendum to the existing entry A facility's EHR software reflects a change in a patient's baseline platelet count. Which of the following methods of notification does the software use to inform the provider? A. An automatic alert message B. An email C. A flag in the patient's record D. A phone call Correct Answer A. An automatic alert message Which of the following functions of the EHR allows coders to query health care providers for clarification during a patient's inpatient hospitalization? A. Work-list reports B. Concurrent coding C. Problem lists D. Care plans Correct Answer B. Concurrent coding (This function allows coders to see documentation while the patients is still receiving treatment so coding can occur on an ongoing basis) An EHR specialist is working with an ophthalmologist. Which of the following types of templates should the EHR specialist create for use during detailed eye examinations? A. Specialized template B. Progress note template C. Treatment plan template D. Problem list template Correct Answer A. Specialized template (The EHR specialist should identify that a specialized template is created to address the specific documentation needs, such as those of an ophthalmologist performing a detailed eye examination) An EHR specialist is assisting a clinical coder with code verification and notes that there is insufficient information in the patient record to support diagnosis coding. Which of the following actions should the EHR specialist instruct the coder to take to request additional documentation from the health care provider? A. Send a provider query B. Telephone the provider C. Text message the provider D. Send the provider a primary source request Correct Answer A. Send a provider query An EHR specialist is reviewing the chart of a patient who is listed as self-pay. Which of the following notes in the chart would indicate to the EHR specialist that the client has Medicare coverage? A. The patient is receiving renal dialysis for end-stage renal disease 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) Correct 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 Correct 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 Correct 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 Correct 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 Correct 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 Correct 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 Correct Answer D. The order is automatically documented in the visit A. "The ICD-10-CM code needs to accurately reflect the procedure provided." B. "The ICD-10-CM code needs to be as shortened as possible." C. "The ICD-10-CM code needs to be based on the MS- DRG." D. "The ICD-10-CM code needs to be as specific as possible." Correct Answer D. "The ICD-10-CM code needs to be as specific as possible." An EHR specialist receives a referral for a new patient. When can the EHR specialist's administrative staff begin the process of verifying insurance eligibility for their services in the EHR? A. When the patient checks in for the appointment B. When the patient has received an explanation of benefits from the carrier C. When the patient checks out after the appointment D. When the patient makes the appointment Correct Answer D. When the patient makes the appointment An EHR specialist is collaborating with a certified coder to create a report needed for evaluation of quality of care for hip arthroplasty surgeries done in the inpatient facility in the past year. The EHR specialist should recognize that which of the following types of codes should be used for their report? A. ICD-10-CM B. ICD-10-PCS C. DSM-5 D. HCPCS Correct Answer B. ICD-10-PCS (ICD-10-PCS codes are used by inpatient facilities for coding procedures) An EHR specialist in a pediatrician's office is working to create a schedule that limits contact between sick children and healthy children by scheduling well-child visits in the morning and sick visits in the afternoon. Which of the following methods of scheduling is the EHR specialist using? A. Open hours scheduling B. Wave scheduling C. Cluster scheduling D. Modified wave scheduling Correct Answer C. Cluster scheduling (In cluster scheduling, similar appointments are scheduled together at specific times. In open hours scheduling, patients are seen by the provider on a first-come, first- served basis; used in urgent care facilities. In wave scheduling, several patients are scheduled to arrive at the same time. In modified wave scheduling, several patients are scheduled to arrive at intervals in the first half hour, and then the provider uses the second half hour to conclude visits with all the patients) An EHR specialist is training a staff member on preventive care documentation available to patients. The staff member asks, "Where do I find recommendations for cervical cancer screening intervals?" Which of the following statements should the specialist make? A. "You can view them on the medical history screen." B. "You can view them on the test results screen." C. "You can view them on the preventive care screen." D. "You can view them on the immunizations screen." Correct Answer C. "You can view them on the preventive care screen." 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." Correct 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. 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 Correct 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." Correct 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 Correct 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 Correct 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 Correct 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. "Before you leave, let me show you where to find this medication education on the patient portal." B. "There is lots of medical information that you can access in the patient portal." C. "The new medication has few side effects." D. "If you have concerns about the medication, I am sure there is information about it on the internet." Correct Answer A. "Before you leave, let me show you where to find this medication education on the patient portal." An EHR specialist is teaching a patient about the patient portal. Which of the following statements should the specialist make? A. "You can update your insurance information." B. "You can update your employee information." C. "You have the ability to contact a doctor immediately in the case of an emergency." D. "You have access to view prescriptions and over-the- counter medications you are currently taking." Correct Answer D. "You have access to view prescriptions and over-the-counter medications you are currently taking." An EHR specialist is assisting a billing specialist with entering codes for durable medical equipment. Which of D. "It streamlines the clinician's workflow." Correct Answer D. "It streamlines the clinician's workflow." Which of the following statements by an EHR specialist correctly de-identifies a patient's information when speaking to a pharmaceutical representative about coverage for a new medication for heartburn? 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." Correct 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 Correct 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." Correct 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 Correct 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 Correct 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. Correct 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 C. Advanced beneficiary notice D. Explanation of benefits form Correct 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 D. Patient's medical record number Correct Answer D. Patient's medical record number An EHR specialist is verifying the accuracy of a production by procedure report. The EHR specialist should identify that which of the following is a purpose of this report? A. To schedule appointments and staff B. To calculate the amount of revenue generated C. To determine the reimbursement amounts by third- party payers D. To sore services by provider Correct Answer B. To calculate the amount of revenue generated A patient witnesses a provider reviewing records using a laptop computer. The patient expresses concern about the security of this practice. Which of the following responses should a clinic staff member make to reassure the patient regarding the provider's security practices? A. "Transmissions to all devices used by our staff take place over a virtual private network." B. "The practice's mobile devices can only be used in the office." C. "Computer technicians update our EHR software regularly." D. "We employ a subcontractor to monitor our systems and notify us immediately if they are compromised." Correct Answer A. "Transmissions to all devices used by our staff take place over a virtual private network." In which of the following instances can a health care organization release protected health information (PHI) without patient authorization? A. A fundraising group requests data regarding the number of patients who have a specific type of cancer B. A research group requests patient records relating to a specific procedure C. The marketing department requests data regarding the number of patients who have heart failure D. The CDC requests health records of patients who have a reportable communicable disease Correct Answer D. The CDC requests health records of patients who have a reportable communicable disease An EHR specialist is preparing a letter of estimated cost for a patient who is scheduled for surgery following completion of drug therapy to treat breast cancer. Which of the following actions should the EHR specialist take prior to preparing the letter? A. Request precertification from the third-party payer B. Collect the required deductible from the patient C. Request the allowed amount from the third-party payer D. Collect a copayment from the patient Correct Answer A. Request precertification from the third-party payer A cardiologist asks the EHR specialist if there is a way to develop a template for heart transplants with information that can be searched. Which of the following types of data would go on this template? A. Diagnostic images B. Text files C. Scanned documents D. Coded data Correct Answer D. Coded data A nurse in an infusion clinic asks the EHR specialist for assistance with discharging a patient who will soon be returning to receive their first infusion of a new medication. Which of the following actions should the EHR specialist take when providing patient education materials? A. Ask the patient for their telephone number to set up an education appointment 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 Correct 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 Correct 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 Correct 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 Correct 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 Correct 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." Correct 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 Correct 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 C. Patient ledger D. Day sheet Correct Answer B. Aging A/R report A patient who is being discharged asks an EHR specialist about how they can find out more information about their condition. Which of the following methods should the EHR specialist recommend? A. Access the patient portal B. Search the internet C. Contact the Health Information Management department D. Ask for information on social media Correct Answer A. Access the patient portal Which of the following features of the clinical decision support system presents a provider with standard plans of therapy for a documented diagnosis or condition? A. Drug formulary B. Protocols C. The task list system D. Medical references Correct Answer B. Protocols A physical therapist asks an EHR specialist for assistance with entering a new e-prescription in the EHR. Which of the following statements should the EHR specialist make? A. "The provider will need to enter the e-prescription." B. "The pharmacist will need to enter the e-prescription." C. "The registered nurse will need to enter the e- prescription." D. "The office manager will need to enter the e- prescription." Correct Answer A. "The provider will need to enter the e-prescription." A provider is performing a history and physical on a patient. Which of the following actions should the provider take to efficiently document the patient's history? A. Write a narrative description of all physical examination findings B. Enter the patient's vital signs on a flow sheet C. Click through each element of the examination and select options from dropdown menus D. Use a template to record the provider's preferred workflow Correct Answer D. Use a template to record the provider's preferred workflow Under the HIPAA Privacy Rule, which of the following individuals can be given directory information about the patient without asking staff for a specific patient's name? A. A patient's relative B. A clergy person C. A patient's friend D. Law enforcement personnel Correct Answer B. A clergy person Which of the following information recorded by a provider during a patient's visit is required during electronic transmission of an order to an outside laboratory? A. Assessment B. Diagnosis code C. Chief complaint D. Treatment plan Correct 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 Correct 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? D. Practice management system Correct 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 Correct 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 Correct 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 Correct 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." Correct 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. Correct 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. B. Operative notes from surgery performed 3 days ago were completed last night C. A cardiology consultation report was reviewed and signed by the provider 48 hr later D. Notes are sent to a professional coder to determine the proper billing codes before being returned to the provider for completion. Correct Answer A. The provider completes a history and physical (H&P) examination within 24 hr after admission. An office manager is considering ways to improve clinic flow so that patients will spend less time completing health history forms in the waiting room. Which of the following methods should the office manager use? A. Ask the patient to arrive 30 min before their appointment to fill out the forms. B. Have the patients review and sign forms from prior appointments An EHR specialist is helping a billing supervisor retrieve an error report before transmitting claims to a payer. Which of the following is used to create the error report? A. Superbill B. Claim scrubbing C. Remittance advice D. Provider query Correct Answer B. Claim scrubbing (Claim scrubbing helps check for edits and billing rules, and it finds errors and generates error reports. This allows staff to review and correct before transmission of the final bill to the payer.) A patient is discharged from the hospital after a total abdominal hysterectomy. The provider lists the procedures as "TAH" in the discharge summary. Which of the following should the compliance team communicate to the provider? 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. Correct 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 Correct 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." Correct 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 Correct 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 Correct 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 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 Correct 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 B. Patient requests pain medication C. Staples intact to right hip incision D. Abduction pillow placed as prescribed Correct Answer C. Staples intact to right hip incision In the event of a computer antivirus update failure, which of the following will mitigate security threats such as a possible data breach? A. Documentation requirements B. Physical safeguards C. Administrative safeguards D. Permitted disclosures Correct Answer B. Physical safeguards An EHR specialist is assisting a nurse in gathering information from a health record to share with a patient about weight control. Which of the following formats would be most useful for the patient to visualize weight fluctuations over a specific timeframe? A. a graph sheet B. A table C. A progress note template D. Physical exam template Correct Answer A. a graph sheet Which of the following methods should an EHR specialist use to verify patient identifiers and ensure information is documented in the correct patient record? A. Review the diagnosis list to determine if it represents the correct patient's record B. Instruct the patient to verify that the medical record has the correct name documented C. Ask another staff member to verify that the patient identifiers are accurate D. Match patient identifier information with information on the record Correct Answer D. Match patient identifier information with information on the record Which of the following documents is a patient required to sign for a health care facility to receive payment directly from the patient's third-party payer? A. Informed consent form B. Notice of Privacy Practices (NPP) C. Assignment of Benefits (AOB) D. Patient encounter form Correct Answer C. Assignment of Benefits (AOB) An EHR specialist is training staff about ways to increase privacy for patients in the waiting room of a provider's office. Which of the following methods should the EHR specialist recommend when calling a patient back to a treatment room? A. Display the patient's full name on an electronic appointment board B. Use the patient's first and last initials C. Have the patient check their name off a list of patients who have appointments that day D. Provide each patient with a number at check-in Correct Answer D. Provide each patient with a number at check-in (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 Correct 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) Correct 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 Correct 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 Correct 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 Correct 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." Correct 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 Correct Answer C. Technical safeguards D. Create new forms to be included in the workflow analysis Correct Answer B. Ask staff members to write detailed descriptions of the responsibilities of their positions A medical coder is leaving a practice for a new position at a different facility. Which of the following actions should the EHR specialist take to prevent unauthorized access to the system? A. Assign a new password to the coder's account B. Terminate the coder's account C. Have the coder sign a contract stating they will not access the account D. Periodically audit the account to ensure it has not been accessed Correct Answer B. Terminate the coder's account An EHR specialist is developing templates for an acute care facility's database. The EHR specialist receives a request to add a field for entering the presence of abdominal pain discovered during a physical examination. In which of the following sections of the template should the EHR specialist document the requested data? A. Respiratory examination B. Neurological examination C. Cardiovascular examination D. Gastrointestinal examination Correct Answer D. Gastrointestinal examination An EHR specialist is locating a patient's chief complaint. In which of the following sections of a SOAP note would this information be found? A. Subjective B. Objective C. Assessment D. Plan Correct Answer A. Subjective (The patient's chief complaint would be found in the subjective data section of the EHR, which includes the patient's reason for the visit in their own words) Which of the following is a messaging standard that translates and interfaces health care data among EHR systems? A. Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) B. Health Level 7 (HL7) C. Logical Observation Identifiers Names and Codes (LOINC) D. Laboratory Information System (LIS) Correct Answer B. Health Level 7 (HL7) (HL7 uses universal specifications to enable smooth translation of data among EHR systems) An EHR specialist is generating a statistical report about measures the facility has take to improve clinical quality. Which of the following is most likely to affect clinical quality? A. Financial status of patients B. Professional appearance of the facility website C. Communication between providers D. Location of facility Correct Answer C. Communication between providers An EHR specialist is assisting an office manager at a family medicine office to plan a training curriculum for new administrative employees. Which of the following references should the manager use when teaching new staff about what data to collect during the patient registration process? A. The Uniform Ambulatory Care Data Set B. Outcome and Assessment Information Set C. The Enterprise Master Patient Index D. The Centers of Medicare and Medicaid Services Security Standards Matrix Correct Answer A. The Uniform Ambulatory Care Data Set (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? the EHR specialist direct the provider to enter the information? A. Progress note B. Clinical results reporting C. E-prescribing D. Medication administration Correct 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 Correct 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 Correct 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 Correct 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 Correct 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 Correct Answer A. Legal data