EHR Specialist Practice Test Questions and Answers, Exams of Laboratory Practices and Management

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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 - ✔✔✔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 - ✔✔✔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." - ✔✔✔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) - ✔✔✔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." - ✔✔✔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. - ✔✔✔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 - ✔✔✔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

(The EHR specialist should look in the physical examination section for the documentation of the patient's height, weight, blood pressure, temperature, pulse, and respirations) Which of the following is an administrative safeguard used to ensure the security of electronic medical records? A. Data backup and storage B. Encryption C. Password management D. Automatic logoff - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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) 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 - ✔✔✔B. Clinical Decision Support System (CDSS) (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 - ✔✔✔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 - ✔✔✔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

B. Flow sheet C. Progress note D. Encounter note - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔B. Demographic information Which of the following patient laboratory findings should be automatically forwarded to the state public health agency? A. Iron-deficiency anemia B. Saliva sample positive for measles C. Positive urine drug screen for a pregnant patient

D. Blood test indicating kidney failure - ✔✔✔B. Saliva sample positive for measles An EHR specialist is assisting a provider with entering a patient's admission data into the health record. In which of the following areas of the EHR should the specialist document the patient's blood pressure? A. Problem list B. Diagnosis list C. Physical examination D. History of present illness - ✔✔✔C. Physical examination An EHR specialist is developing templates for a facility's EHR database. In which of the following sections of the EHR should the specialist place the progress note? A. Legal data B. Clinical data C. Financial data D. Administrative data - ✔✔✔B. Clinical data A provider orders a laboratory test in the EHR. Which of the following describes the way laboratory specimens are labeled and tracked? 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 - ✔✔✔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 - ✔✔✔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)

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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔B. Concurrent coding

C. Review the IT company's record filed with its state regulatory agency D. Enter into a business associates contract with the IT contractors - ✔✔✔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) - ✔✔✔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 - ✔✔✔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) - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔B. Validate the procedure code with documentation in the patient health record

D. "Templates can be merged into an encounter note." - ✔✔✔C. "Templates can be customized to work with each provider's workflow." (Templates allow for customizable entry and display of data elements so providers can work in a way they determine to be the most efficient) An EHR specialist is collaborating with a certified coder in a training session for outpatient billers after getting a new EHR system. Which of the following statements about the ICD- 10 - CM codes should the EHR specialist make? 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." - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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." - ✔✔✔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." - ✔✔✔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 - ✔✔✔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 - ✔✔✔A. By diagnosis

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." - ✔✔✔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 - ✔✔✔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 - ✔✔✔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 - ✔✔✔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." - ✔✔✔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." - ✔✔✔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 the following manuals should the EHR specialist instruct the patient billing specialist to use? A. HCPCS manual B. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) C. CPT manual D. ICD- 10 - CM manual - ✔✔✔A. HCPCS manual (The HCPCS manual is primarily used to bill for products, supplies, and services not included in the CPT manual, including durable medical equipment) An EHR specialist is accessing the results of a patient's MRI. Which of the following is the radiology department software used to store diagnostic images? A. Radiology information systems (RIS) B. Picture archiving and communication systems (PACs) C. Computerized provider order entry system (CPOE) D. Computed axial tomography (CT) - ✔✔✔B. Picture archiving and communication systems (PACs) Which of the following sections of the HIPAA Security Rule governs the encryption and decryption of data for secure transmission? A. Administrative safeguards B. Technical safeguards C. Physical safeguards D. Organizational requirements - ✔✔✔B. Technical safeguards (Administrative safeguards section covers individual security responsibilities and security and safety training for users and employees; physical safeguards sections pertains to the mechanism used to protect electronic systems from intruders, including off-site computer