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Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology?


A) Appointment scheduler
B) Charge capture
C) Referral management
D) Medical billing system

E) All of the above
F) B) and C)

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Medical facilities should keep records on minors for how long?


A) Indefinitely
B) Until the minor is deceased
C) For 10 years
D) Until the minor reaches the age of majority, plus the statute of limitations

E) C) and D)
F) B) and D)

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Very little statistical information can be gleaned from an EHR system.

A) True
B) False

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The type of electronic record of health-related information about an individual that can be created, gathered, managed, and consulted only by authorized clinicians and staff in a single healthcare organization is a(n)


A) PHR.
B) EHR.
C) EMR.
D) PHI.

E) A) and B)
F) A) and D)

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A process of electronic data entry of the provider's instructions for the treatment of patients is called _______________.


A) EMR
B) PHI
C) CPOE
D) All of the above

E) None of the above
F) C) and D)

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Most experts agree that the EHR system will help reduce medical __________.


A) errors
B) confusion
C) upkeep
D) space

E) B) and C)
F) A) and D)

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How would you properly index the name "Jill Freeman, M.D." for filing if you had another patient with the same name but without the title?


A) Dr. Jill Freeman
B) Freeman, Dr. Jill
C) Freeman, Jill
D) Freeman, Jill M.D.

E) All of the above
F) A) and B)

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The EHR system's __________ component allows the physician's staff to communicate with and send claims electronically to insurance companies.


A) medical billing
B) charge capture
C) eligibility verification
D) All of the above

E) A) and B)
F) A) and C)

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The medical record should be released only with a


A) verbal order from the physician.
B) written order from the physician.
C) written release from the patient.
D) verbal order from the office manager.

E) A) and D)
F) B) and C)

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The type of electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization is a(n)


A) EMH.
B) EHR.
C) EMR.
D) PHI.

E) None of the above
F) All of the above

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The process of moving an active file to inactive status is called


A) purging.
B) indexing.
C) coding.
D) conditioning.

E) A) and C)
F) None of the above

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The EHR system is not capable of telling whether a certain procedure matches a specific diagnosis code.

A) True
B) False

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For a record to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written. The best indication of this is the provider's signature or initials on the typed or EHR entry.


A) Both statements are true.
B) Both statements are false.
C) The first statement is true; the second is false.
D) The first statement is false; the second is true.

E) B) and C)
F) B) and D)

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Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files.


A) inactive
B) closed
C) active
D) dead

E) A) and B)
F) A) and C)

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The concise account of the patient's symptoms in his or her own words is the __________.


A) social history
B) history of present illness
C) chief complaint
D) diagnosis

E) None of the above
F) B) and D)

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A process to ensure the reliability of test results often using manufactured samples with known values is known as


A) parameter.
B) interface.
C) compliance.
D) quality control.

E) A) and B)
F) A) and C)

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What is the HIPAA privacy rule requirement for the retention of health records?


A) HIPAA does not include requirements.
B) Records must be kept for at least 10 years.
C) For at least the period of the statute of limitations for medical malpractice claims.
D) Until the minor reaches the age of majority plus the statute of limitations.

E) A) and C)
F) All of the above

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