Which of the following is the maximum n umber of days a provider's office has to notify
patient's when there is a breach to medical record security?
A. 30 days
B. 40 days
C. 60 days
D. 90 days - ANSWER ✔✔C. 60 days
Which of the following is a benefit of documenting a patient encounter at the poi nt of care?
A. increased number of referrals
B. decreased supply cost
C. improved patient outcomes
D. diminished wait times - ANSWER ✔✔C. improved patient outcomes
An EHR specialist is coding for the reimbursement of durable medical equipment. Which
of the following code sets should she use?
A. ICD -10-CM
B. CPT
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C. CDT
D. HCPCS - ANSWER ✔✔D. HCPCS
Which of the following is included on a face sheet?
A. advance directi ves
B. discharge diagnosis
C. medications prescribed during the visit
D. appointment information for follow -up-visit - ANSWER ✔✔A. advance directives
A patient is being seen in a clinic for a follow -up visit. The medical assistant has gathered
the patient's vital signs. In which of the following should this information be entered?
A. PHR
B. ePrescription
C. laboratory section
D. EMR - ANSWER ✔✔D. EMR
An EHR specialist is reviewing patient records to ensure charts are being properly
completed. Which of the fo llowing tasks is he performing?
A. reindexing
B. scanning
C. auditing
D. restoring - ANSWER ✔✔C. auditing
An EHR specialist is coding a claim for a patient who fell off a chair and broke an arm.
Which of the following is necessary to explain the patient's condition in full?
A. HCPCS Level II modifiers
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B. J codes
C. bundled codes
D. V-Y codes - ANSWER ✔✔D. V-Y codes
Which of the following federal acts mandates physical, technical, and administrative
safeguards?
A. FECA
B. MMA
C. HIPAA Title II
D. HITECH - ANSWER ✔✔C. HIPAA Title II
Which of the following statements would be documented in the physical examination?
A. admitted because of regular contractions
B. had tonsillectomy 3 years ago
C. prefers chewable tablets to liquids
D. negative bowel sounds - ANSWER ✔✔D. negative bowel sounds
A patient is admitted with tonsillitis for which a tonsillectomy was performed. During the
recovery, the patient fell and fractured the right ulna, requiring reduction of the bone. The
principal procedure will be l isted as ...?
A. tonsillitis
B. tonsillectomy
C. fractured ulna
D. reduction of ulna - ANSWER ✔✔B. tonsillectomy
Which of the following is the first step when processing a record request in a manual
system?
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A. locate the record on the shelf
B. verify the name and record number
C. place a requisition slip in the outguide
D. validate authorization for release - ANSWER ✔✔D. validate authorization for release
Which of the following is the coding system used to convert written diagnosis into numeric
form?
A. CP T
B. HCPCS
C. ICD
D. CMS - ANSWER ✔✔C. ICD
An EHR specialist has the medical record of a patient who was admitted through the
emergency department and stayed in the hospital 7 days. The patient lives out of state
and never returned to the facility after discharge. Which of the following applies to the
patient's record?
A. The record may not be destroyed unless the EHR specialist receives signed
documentation from the patient stating he lives out of state and will never be back in the
facility.
B. The record may not be destroyed.
C. The record may b e destroyed after 5 years.
D. The record may be destroyed based on the information collected from the patient at the
time of treatment. - ANSWER ✔✔A. The record may not be destroyed unless the EHR
specialist receives signed documentation from the patient st ating he lives out of state and
will never be back in the facility.
Which of the following is considered an incomplete record?
A. A signed report that was complete 1 week before the patient was admitted.
B. A discharge summary the provider has not signed 45 days after discharge. Powered by TCPDF (www.tcpdf.org)
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