Introduction to EHR Palmer Practice Test

These questions are part of the practice quiz. Start practicing

• What is the primary purpose of a daily visit in a clinical setting?
• Which components are included in a daily visit note?
• What is the purpose of the care plan in the medical note?
• What does the "O" in SOAP note stand for?
• Which section of the record would you expect to find the rationale for the chosen treatments?
• What is the first step in performing a self-audit according to the lecture?
• What is the primary focus of this week's lesson according to the text?
• _______ term goals are where you expect to be at the end of the care plan, with that end date stated.
• Which components are described as part of the subjective history in the material?
• In the SOAP note, which part covers what you found during examination?
• What should be avoided in patient records?
• In the X-ray ordering sequence, what should the Lab company setting be?
• According to the lecture, what was the rate of improper payments by Medicare in 2023?
• Which area contains Palmer documentation templates?
• Which element of the subjective entry is designed for a detailed narrative of symptoms?
• Why are self-audits important?
• Where is class work stored in the academic setting?
• What is the final action to assign the note to the course instructor?
• Which color represents insurance details?
• What does ICW stand for in this context?
• How should goals be addressed in the care plan?
• What does CPT code 98943 represent?
• What should be reviewed prior to the patient coming in for a daily visit?
• What is the primary factor for determining the level of E&M code?
• Which statement is true about the diagnosis in the patient record?
• What is the first step in the process from scheduling a patient to assigning the note to the instructor?
• What must be included in the patient demographics section of the health records?
• What does the assessment section commonly include?
• What has been identified as the biggest cause of improper payment according to Medicare data from 2020 to 2023?
• What Rx Type should be selected when ordering an x-ray?
• What happens when you click 'Assign' in the rehab referral process?
• When is an evaluation and management (E&M) code billed for?
• Which statement best describes the role of electronic health records in patient documentation?
• Which of the following is NOT a component to check during a self-audit?
• What is the name of the EHR system currently used in the clinic?
• How is the severity of a presenting problem categorized in E&M coding?
• Which of the following is NOT a component to check during a self-audit?
• Diagnosis codes are explained with words in the diagnostic statement in the ______ section of the patient's record.
• In the SOAP note, which part covers what you think about the patient?
• Which step in the sequence requires selecting the X-ray study being ordered?
• What are the two parts of the SOAP note discussed this week?
• What does the patient complaint section in the EHR primarily describe?
• What information should be included in your academic patient file?
• How are the codes 97012 and 97014 differentiated in therapy?
• What should be included in the assessment section of a SOAP note?
• Which E&M code is not used for patients in the clinic?
• What should be done if diagnosis codes are missing in the billing window?
• _______ codes are supported by the history obtained from the patient and exam findings?
• What is the purpose of the objective section in a SOAP note?
• In the SOAP note, which part covers what the patient tells you?
• What should be done if major errors are found in most of the 10 files during a self-audit?
• What is the purpose of the visit summary in the assessment section?
• What does a well-crafted care plan help ensure?
• The practice of documenting HPI for each region being treated primarily ensures what?
• Which code would be considered a New Patient E/M code?
• In the described EHR workflow for ordering an X-ray, which is the first step?
• Which action assigns the referral note to the clinic provider?
• Which condition is indicated by the diagnostic code m99.01 in the provided example?
• True or False: Appropriate goals address improvement in pain and function, when relevant, and have a documented end date.
• What is the role of the care plan in patient treatment?
• In medical documentation, how should the assessment relate to the plan?
• In the ECW system, what is the purpose of the navigation bar?
• During a self-audit, which areas should be investigated?
• What is the purpose of the diagnosis in patient care as documented in the assessment?
• Which browser is recommended for accessing the EHR Palmer system?
• In the rehab referral sequence, after opening Referrals, what is the next screen you access?
• In SOAP notes, what does the Subjective section capture?
• After filling in the template, what is the next action?
• What is the final step in the process of ordering an x-ray study?
• What is the purpose of E&M coding in a medical setting?
• What is the first step in completing the homework assignment related to the care plan?
• A patient who has not been seen in the office within the last three years would be considered what for E&M coding on their next visit?
• Which two elements are primarily used to determine the level of E&M service?
• During referral creation, what action captures the referral rationale?
• In ECW, what does the M jelly bean indicate?
• Documenting a subjective history in each region you adjust is required.
• _______ term goals are measured throughout the course, on the way to long term goals.
• What is considered an Established Patient?
• What role do exam findings play in the SOAP note process?
• What should be documented for each region of the spine that is adjusted?
• According to the Florida Administrative Code 64B, why is minimal documentation required?
• What is the importance of setting specific measurable goals in a care plan?
• Which statement best explains why proper documentation is needed in health care?
• Where is the patient's medical history entered in the chart?
• During a daily visit note, which sections are updated?
• What action should be taken if major errors are found in most of the 10 files during a self-audit?
• The procedure codes are found under the:
• Which factor is commonly considered primary in determining E&M level?
• What is required by the Florida Administrative Code 64B for chiropractic practices?
• How should CPT codes be linked to ICD-10 codes?
• In the SOAP note, which part describes what you did and how you did it?
• Which of the following is not an established patient E/M code?
• Where should you click to log out?
• What determines the E&M code billed for a new patient?
• To view a rehab referral in the EHR system, where do you navigate first?
• Why is it important that the facility listed in your appointment screen is correct with respect to the class you are working in?
• What is the role of ICD-10 codes in the diagnosis process?
• All previous visit dates and notes are found in which section?
• Which action correctly logs you out of the system?
• Which outcome is expected after correcting issues identified by a self-audit?
• What is typically included in the plan section of a daily visit documentation?
• What is the purpose of conducting a comprehensive file review (CFR) in the clinic?
• What is required to bill for a time-based therapy code under the 8-minute rule?
• How can you ensure you are working on the correct progress note in the EHR?
• What is the first step in performing a self-audit according to the lecture?
• Before clicking "save" when creating a new patient account, what should you do?
• What is the approximate rate of Medicare improper payments in 2023?
• Which coding system is explicitly described as alphanumeric for diagnoses?
• Which CPT code is part of Established Patient E/M codes?
• In the rehab referral viewing workflow, which element is used to access the detailed referral information?
• What is the primary purpose of the course taught by Dr. Jordahl?
• Which step is used to initiate the specific x-ray study being ordered?
• After selecting the assessment code linked to the x-ray being ordered, what must you do next?
• What is the initial action to start a rehab referral in the EHR workflow?
• In a SOAP note, which component includes measurements and exam findings?
• What is the primary focus of this week's lecture in the context of EHR? (week 3)
• If you need to change something on a scheduled appointment, what is the correct sequence?
• What is the primary purpose of conducting a self-audit for file quality assurance in the clinic?
• How is diagnosis documented in the SOAP note according to the text?
• Evaluation and Management (E/M) code 99211 means:
• What is the significance of documenting medical necessity in EHR?
• How does the duration of a daily visit compare to the initial visit for more experienced interns?
• Which factor is least likely to affect the E&M coding level under typical guidelines?
• How are diagnosis codes documented?
• Which jelly bean is used to navigate to the resource schedule, tracking board and to review progress notes?
• Which SOAP component captures the patient’s own report of symptoms?
• What should you do if you cannot find a provider in the "my providers" list?
• What is the purpose of the S jelly bean in the ECW system?
• What is the purpose of the 8-minute rule in therapy coding?
• Which element is used to capture patient-reported symptoms in their own words?
• Which statement is false regarding linking CPT codes to ICD-10 codes?
• What is the name of the screen in eCW where you schedule a patient appointment?
• Who establishes the minimum amount of time for storage retention?
• Why is it necessary to document the history of present illness (HPI) for each region being adjusted?
• Which option is NOT a component of the treatment (care) plan?
• What is the correct step to perform when starting to create a new patient file in ECW?
• What determines whether a patient is billed with new or established patient E&M codes?
• In a SOAP note, which component contains the treatment plan and follow-up actions?
• In eCW, when you insert an Initial HPI template, what happens to associated examination templates?
• What is the purpose of the care plan in medical documentation?
• Which part of the SOAP note is updated with the patient's current problem presentation during a daily visit?
• Which statement describes how CPT codes should be linked to ICD-10 codes?
• What is the purpose of sticky notes in the ECW system?
• In the EHR, which tab houses Labs, Diagnostic Imaging, Telephone/Web Encounters, Referrals, and Documents?
• What Lab and DI Company settings should be used when ordering an x-ray?
• Evaluation and Management (E/M) code 99201 means:
• Which action adds the diagnosis/assessment codes to the referral?
• What are the two components of the subjective history in the chain of medical necessity?
• Which action helps identify and remove an incorrectly entered template in the EHR?
• How should daily visits relate to the initial visit in terms of care?
• What does a red M jelly bean indicate in the ECW system?
• Which color represents appointment details sticky note?
• Which action inserts the correct template into the progress note?
• In the context of daily visits, what is a common focus regarding patient management?
• How often should a physician perform a self-audit for file quality assurance?
• Which step involves clicking the date when the study is ordered?
• Documentation templates in Palmer's EHR are used to standardize notes.
• Which statement best explains how proper documentation affects insurance reimbursement?
• What is the primary purpose of the course 'Introduction to EHR'?
• Adjustment credit is awarded only for work performed in certain classes.
• In the patient record, where is the rationale for the chosen treatments documented?
• Which color represents secure notes?
• What factors influence the level of E&M coding?
• According to the lecture, what was the rate of improper payments by Medicare in 2023?
• What are the components of the medical document mentioned in the lecture?
• How will the course content be delivered?
• Which of the following is a primary focus in the described SOAP notes framework?
• What is the significance of the M99.0X code in chiropractic manipulative therapy?
• Which information is required when entering your name in the new patient account?
• CPT code 98943 covers adjustments to which regions?
• What is considered a New Patient?
• What is the first step in creating a new patient file in the ECW system?
• Which statement about E/M code 99201 is accurate?
• What is the primary purpose of conducting a self-audit for file quality assurance in the clinic?
• What is the primary focus from week 6 lecture? (care plan)
• Why is it important to document both the listing and the technique used in the adjustments?
• Medical necessity in EHR documentation is intended to ensure what?
• What is the first step in entering information into the subjective note of the EHR?
• Which jelly bean color indicates high-priority messages in ECW?
• Why is documenting medical necessity important?
• T/F: The diagnostic code m99.01, which indicates cervical dysfunction, is directly linked the the procedure code 98940, which is used for a cervical adjustment in one region.
• When preparing to order an x-ray, which set of filter boxes should you select to limit options?
• CPT code 97014 is used for which modality?
• What is the sample size for the self-audit as described?
• What should be included in a daily SOAP note according to the course?
• Which statement best describes the treatment plan in relation to the diagnosis?
• What is the main purpose of CFR?
• In the academic setting, all class work goes under YOUR patient account. Which statement is correct?
• Which color represents non-secure clinical notes?
• Which SOAP section describes the plan for future care?
• In SOAP notes, what does the Objective section typically capture?
• What is the purpose of the SOAP note in patient documentation?
• In the X-ray ordering sequence, what should the DI company setting be?
• What are some key elements to check during a self-audit?
• Which statement best describes the M99.0X code's role in treatment coding?
• What should be done if a template is incorrectly entered into the EHR?
• Which action would you use to access different areas of the ECW system?
• Which section of the SOAP note is used to record the clinician's direct observations during examination?
• Where can you locate the Problem List, Allergies, and Medication in the patient record?
• What element is commonly associated with medical necessity in clinical documentation?
• What is the purpose of the free form box in the EHR subjective component?
• Which statement best describes the course delivery method used for the course?
• The statement 'The diagnosis links the subjective and objective findings to the treatment plan' is:
• What is the significance of matching treatment to diagnosis in a care plan?
• What happens to changes after the rehab provider has addressed the order?
• Which step is associated with preparing a new patient account before saving it?
• Which statement best describes where to add missing providers in ECW?
• Which statement best describes medical necessity?
• _______ codes are used to identify medical services and procedures performed by the doctor.
• What typically happens during a daily visit note entry?