HIM 110 - Chapter 7 Homework

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formulary

A list of pharmaceutical products and dosages deemed by a health care organization to be the best, most economical treatments for a condition or disease.

evaluation and management (E/M) codes

The CPT codes that represent the thought process that the physician follows to determine the best course of care.

ICD-9-CM

The ninth revision of the International Classification of Diseases, which is used for diagnosis codes in the United States.

Tabular List

The section of the ICD-9-CM in which diagnosis codes are presented in numerical order.

dictation

The process of recording spoken words that will later be transcribed into written form.

medical coding

The process of applying the HIPAA-mandated code sets to assign codes to diagnoses and procedures

computer-assisted coding

The process of coding with software.

primary diagnosis

The diagnosis that relates to the patient's stated reason for the visit.

voice recognition software

A computer program that can recognize spoken words.

template

A preformatted file that serves as a starting point for a new document.

True

In Medisoft Clinical Patient Records, the Rx/Medications folder in a patient's chart is used to order new medications and monitor current, historical, or ineffective medications. (T/F)

False

Many physicians prefer to use dictation and transcription because it is the most efficient method of entering documentation. (T/F)

True

In Medisoft Clinical Patient Records, orders are checked to determine if they are inappropriate for a patient based on factors such as allergies. (T/F)

False

When a template is used to create a progress note, it is not necessary to enter patient-specific information. (T/F)

True

When an EHR is used for e-prescribing, a new prescription can be automatically checked for drug interactions, appropriate dosage levels, and patient allergies. (T/F)

True

The procedure codes for physicians' and other health care providers' services are selected from the Current Procedural Terminology data set, called CPT. (T/F)

True

When an electronic encounter form (EEF) is used to record a patient's procedures and diagnoses, it is not necessary to complete a paper form. (T/F)

False

SOAP stands for Subjective, Objective, Assessment, and Procedure. (T/F)

True

Most codes in the E/M section are organized by the place of service, such as the office, the hospital, or a patient's home. (T/F)

False

In Medisoft Clinical Patient Records, order processing begins with selecting Orders > Order Processing on the Lists menu. (T/F)

Category II codes

________ are used to track performance measures for a medical goal such as reducing tobacco use.

diagnoses

In Medisoft Clinical Patient Records, orders can be checked against insurance company rules to determine if a test requires preauthorization or is limited to certain _________.

title

In Medisoft Clinical Patient Records, every progress note starts with a date and a ________.

Voice-recognition software

________ transcribes spoken words into text in an electronic file.

Coding

In the Electronic Encounter dialog box, the three tabs are Procedures, Diagnoses, and _________.

Medical Coding

________ is the process of applying the HIPAA-mandated code sets to assign codes to diagnoses and procedures.

all of the above (dictation and transcription, voice recognition software, a template)

In Medisoft Clinical Patient Records, progress notes can be entered through the use of ________.

5 to 7

ICD-10-CM codes contain ________ characters, while ICD-9-CM codes consist of 3 to 5 characters.

CPT

The procedure codes for physicians' and other health care providers' services are selected from the ________.

easy to learn

Which of the following is not an advantage of using a template to enter a progress note? (efficiency, computer search and analysis information less likely to be omitted, easy to learn)

Note

To open a shared note, click the ________ toolbar button.

Click the Chart button on the toolbar, enter the first several letters of the patient's last name in the Last Name field, Click the Lookup button, Select the patient and click the OK button, Click the Note button on the toolbar, In response to the message about a shared note, click the Yes button

False

When entering a progress note wihtout using a template, it is not necessary to enter note headings such as Subjective.

True

The Objective section of a progress not includes a patient's vital signs.

True

To create a new progress note, a patient's chart must be open.

Assessment

The ________ section of a progress note contains the physician's diagnosis of the patient

True

To enter a physician's assessment of a patient's condition in Medisoft Clinical Patient Records, the patient's chart must be open.

signature password

To electronically sign a note, enter the physician's _________ in the Signature field.

False

When "no" is clicked in response to the question about whether the user is permanently done with the note, the Enter Signature dialog box appears.

False

The plan section of a progress note contains the results of a patient's laboratory tests.

Insert

The Template command that is used to insert a template in to a progress note is located on the ________ menu.

Insert Quick Text

When a red label such as NewProb (new problem) is clicked in a progress note, the ________ dialog box appears.

Subjective

The Review of Systems is located in the ________ section of the progress note.

disappears

When a blue label such as Skin is clicked in a progress note, the label ________ and text appears.

skipped

Labels in the Objective section of the note that are not mentioned in the documentation should be ________.

CHRONIC DISEASE DIAGNOSES

When the ________ label in the Assessment section of a progress note is clicked, a list of chronic diseases is displayed.

True

when a disease diagnosis such as Hypertension Unspecified is clicked in the Assessment section of a progress note, the program automatically enters the IDC-9-CM diagnosis code.

Insert Quick Text

When the Disease Status label is clicked in the Assessment section of a progress note, the ________ dialog box appears with a list of choices.

ePrescribe Some Rx

When the ePrescribe label is clicked in the Plan section of a progress note, the options displayed include ePrescribe No Rx, ePrescribe All Rx, and ________.

PRN

The labels next to the word Follow-up in the Plan section of a progress note include DEL, F/U, and ________.

Enter Signature

When the Yes button is clicked in response to the Permanantly done with note? query, the ________ dialog box is displayed.

Rx Template Code

To lookup a prescription template, an entry is made in the ________ field of the Prescription dialog box.

Route

When a prescription template is used, the program automatically completes some of the fields in the Prescription dialog box, including Medication, Size, Take, Frequency, Amount, and ________.

Drug Interaction Check

To ensure that the medication being prescribed is checked for any possible interaction with a patient's current medications and allergies, the Allergy Check and ________ boxes should be checked in the prescription dialog box.

Add

To add a test from the Order Tree panel to the order queue, select the test name and click the ________ button.

Operator

The Order (new) dialog box includes areas for patient instructions and ________ instructions.

STAT

The options for selecting the urgency of a test include Routine, Do within X days, Do in X days, and ________.

Forms

To print an order from the Order Processing Select dialog box, click the ________ button.

Orders

To view the Order Processing dialog box, click ________ on the Task menu, and then select Order Processing.

Task

The Electronic Encounter Forms option is located on the ________ menu.

Chart

To view visit documentation while reviewing the electronic encounter form, click the ________ button on the toolbar.

drag

To assign the diagnosis code to each of the procedure codes in the Electronic Encounter (new) dialog box, click and hold the mouse button and ________ the diagnosis to the first entry in the Procedure Selection column.

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