Chapter 11
Important information about a patient's medical history and present condition is found in the ____.
patient's chart
Which step of "meaningful use" of EHRs for Medicare and Medicaid patients includes documenting the percentage of visits, diagnoses, prescriptions, immunizations, and other pertinent health information electronically?
Step 1
Which of the following documents indicates who is responsible for the various types of calls in the office and how the calls are to be handled?
routing list
Which of the following types of preoperative teaching supplies details about the surgical procedure?
Factual
Learning to perform new skills is part of the ________ domain of learning.
psychomotor
Which of the following organizations reviews patient charts to monitor whether the care provided and the fee charged meet accepted standards?
The Joint Commission
Which of the following is not likely to be a required field in your EHR software's form to be completed for each new patient?
Patient driver's license
How much time should you allow for a patient to answer when you place a phone call?
One minute or about eight rings
Theoretical or practical understanding of a subject and the ability to recall it is part of which learning domain?
Cognitive
The type of documentation that provides an orderly series of steps for dealing with any medical case is ____.
SOAP
In legal terms, medical records regarded as ____ may damage a physician's position in a lawsuit.
convenient
Many offices and EHR systems today allow patients to access and interact with certain parts of their EHR by providing a patient ____ to the system.
portal
One of the most important telephone skills is saying words correctly, which is called ____.
pronunciation
Learning falls in to three main categories that are known as the ____ of learning.
domains
What percentage of the U.S. gross national product is accounted for by healthcare costs?
5%
The diagnosis made by the physician is found in which section of the CHEDDAR format of documentation?
Assessment
An EHR function that can alert staff members about patients who are due for yearly checkups and patients who require follow-up care uses computerized records as ________ files.
tickler
Telephone ________ means handling calls politely and professionally and with good manners.
etiquette
Preventive measures in healthcare includes health-promoting behaviors, screening, and ____.
rehabilitation
Which of the following is a disadvantage of implementing an EHR system?
Staff training requirements
When you document according to a numbered problem, the chart is arranged by the ________-oriented medical record system.
Problem
Even if an electronic coding program is used, an experienced coder should perform random internal coding ________ several times a year to ensure that coding is being performed correctly.
audits
Speaking with good ________ enables the person to whom you are speaking to understand you.
enunciation
Becoming motivated and learning to have a positive attitude fall under the ________ domain of learning.
Affective
The recommended procedure for handling billing inquiries is to ____.
pull the patient's chart and billing information