Fordneys Chapter 11 Exam UPDATED
ACTUAL QUESTIONS AND CORRECT
ANSWERS
List the two types of health record systems that can be used in medical practice - CORRECT
ANSWER Problem-oriented Medical record system (POMR) - charts and graphs and
Source-oriented record system (SOR) - filed by document type.
What is the CMS definition of legible documentation? - CORRECT ANSWER that the
data must be easily recognizable by someone outside of the medical practice who is
unfamiliar with the handwritting
EMR vs EHR - CORRECT ANSWER EMR is individual physicians record of patients
care. EHR is all the patient's records from many different information systems and providers.
The performance of services or procedures consistent with the diagnosis, . done with
standards of good medical practice and proper level of care given in the appropriate setting is
what? - CORRECT ANSWER Medical Necessity
Define New Patient and Established Patient - CORRECT ANSWER New patient - one
who has not received any professional services within the last 3 years from the physician or
another physician of the same specialty who belongs to the same medical group.
Established patient - one who has received professional services from physician or another
physician of the same specialty who belongs to the same medical group.
consultation - CORRECT ANSWER Services rendered by a physician whose opinion
or advice is requested by another physician or agency in the evaluation or treatment of a
patient's illness or suspected problem.
referral - CORRECT ANSWER Transfer of patient care from one physician to another.
, concurrent care - CORRECT ANSWER care being provided by more than one
physician, such as a primary care physician and a specialist on the same day.
continuity of care - CORRECT ANSWER medical care for a patient who has received
treatment for an illness and is referred to a second physician for treatment of the same
condition.
Critical Care - CORRECT ANSWER refers to intensive care provided for a variety of
acute, life-threatening conditions requiring constant full attention by a physician. A critical
illness or injury impairs one or more vital organ systems.
Emergency care - CORRECT ANSWER care provided to acutely I'll patients that may
or may not involve organ system failure but does require immediate medical attention.
Counseling - CORRECT ANSWER A discussion between the physician and a patient,
family, or both concerning the diagnosis, recommended studies or tests, prognosis, risks, and
benefits of treatment, treatment options, patient and family education, and so on
eponym - CORRECT ANSWER term including the name of a person.
acute - CORRECT ANSWER condition that runs a short but severe course - typically
3-5 days.
chronic - CORRECT ANSWER a condition persisting over a long period of time, often
more than 3 months.
subacute - CORRECT ANSWER a condition that is both acute and chronic.
For EHR, how should and insurance billing specialist correct an error? - CORRECT
ANSWER Note that a section is in error with date and time and enter correct info with
a notation of what and why physician changed the entry. Authenticate the correction with
electronic signature and date.
ACTUAL QUESTIONS AND CORRECT
ANSWERS
List the two types of health record systems that can be used in medical practice - CORRECT
ANSWER Problem-oriented Medical record system (POMR) - charts and graphs and
Source-oriented record system (SOR) - filed by document type.
What is the CMS definition of legible documentation? - CORRECT ANSWER that the
data must be easily recognizable by someone outside of the medical practice who is
unfamiliar with the handwritting
EMR vs EHR - CORRECT ANSWER EMR is individual physicians record of patients
care. EHR is all the patient's records from many different information systems and providers.
The performance of services or procedures consistent with the diagnosis, . done with
standards of good medical practice and proper level of care given in the appropriate setting is
what? - CORRECT ANSWER Medical Necessity
Define New Patient and Established Patient - CORRECT ANSWER New patient - one
who has not received any professional services within the last 3 years from the physician or
another physician of the same specialty who belongs to the same medical group.
Established patient - one who has received professional services from physician or another
physician of the same specialty who belongs to the same medical group.
consultation - CORRECT ANSWER Services rendered by a physician whose opinion
or advice is requested by another physician or agency in the evaluation or treatment of a
patient's illness or suspected problem.
referral - CORRECT ANSWER Transfer of patient care from one physician to another.
, concurrent care - CORRECT ANSWER care being provided by more than one
physician, such as a primary care physician and a specialist on the same day.
continuity of care - CORRECT ANSWER medical care for a patient who has received
treatment for an illness and is referred to a second physician for treatment of the same
condition.
Critical Care - CORRECT ANSWER refers to intensive care provided for a variety of
acute, life-threatening conditions requiring constant full attention by a physician. A critical
illness or injury impairs one or more vital organ systems.
Emergency care - CORRECT ANSWER care provided to acutely I'll patients that may
or may not involve organ system failure but does require immediate medical attention.
Counseling - CORRECT ANSWER A discussion between the physician and a patient,
family, or both concerning the diagnosis, recommended studies or tests, prognosis, risks, and
benefits of treatment, treatment options, patient and family education, and so on
eponym - CORRECT ANSWER term including the name of a person.
acute - CORRECT ANSWER condition that runs a short but severe course - typically
3-5 days.
chronic - CORRECT ANSWER a condition persisting over a long period of time, often
more than 3 months.
subacute - CORRECT ANSWER a condition that is both acute and chronic.
For EHR, how should and insurance billing specialist correct an error? - CORRECT
ANSWER Note that a section is in error with date and time and enter correct info with
a notation of what and why physician changed the entry. Authenticate the correction with
electronic signature and date.
