Chapter 006 – The Office Visit

An encounter with a medical provider is whch the patient’s chief complaint, body systems, vitals, physical exam, diagnoses, and medication are review and documented.
Which of the following is and office visit as defined by SpringCharts ?

Subjective, Objective, Assessment, and Plan
S.O.A.P is an acronym for which of the following ?

The navigation panel along the right side of the OV screen.
What feature in SpringCharts enables the user to proceed through the office visit in a logical flow ?

(all of these)

– Chief complaints.
– History of present illness.
– Review of system.

Which of the following features are included on the navigation panel of the OV window ?

It is the documentation of a patient’s face sheet and medical history combined with physical exam.
Which of the following best describes a History & Physical (H&P) Report ?

It enables a clinician to time and initial stamp a portion of the office visit note.
What function of the [time and initial] button ?

Body Mass Index
BMI is an acronym for which of the following ?

Review if System
Which of the following is a structured technique used by providers to gather healtcare history covering the organs from the patient ?

It displays an information window from the patient chart related to Allergies and Other Sensitivity.
What does accessing the prescription [Rx] navigation tab display ?

( all of these are business associates)

– Clearinghouses
– Insurance companies
– Testing facilities

Which of the following are considered business associates under HIPAA regulations. Require them to follow the practice’s guideline to ensure that patient PHI remain secure and private ?

(all of these)

– Description of sign and symptom
– History of present illness
– Social condition

Which of the following could be included in a diagnostic inquiry preformed by a physician ?

(all of these)

– Face sheet overview
– Office visit note
– Pop-up text window

Which of the following is a main section of the OV window ?

pain
Which of the following would be documented in the Subjective section of S.O.A.P notes ?

[Add Pt Ins]
Which of the following buttons is used to add a patient’s primary insurance to the test order form ?

Prescription form
Which of the following can also be created by the order form ?

Create a Reminder
Which icon in the OV screen enables the provider to send a To-Do/Reminder to another person in the clinic or to him/herself ?

Initial Only
Which of the following signature option allow the note to be recalled for further edits ?

It cannot be unlocked or edited by anyone.
Once an office visit is locked with the Permanent Sign & Lock feature, who may unlock or edit the office visit ?

The date the office visit note was first created.
The Date of Service will automatically default to which date ?

None of these
Editing an unlocked office visit note at a future date updates which of the following ?

(All of these are methods of data entry in an office visit note.)

– Tapping on pop-up text with stylus
– Clicking on pop-up text with a mouse.
– Typing directly in the text box.

Which of the following is NOT a method to enter data into the office visit note ?

Show chart summary
Which of the following Tabs allow the user to enter all text into the S.O.A.P notes and view the entire note?

Pop-up text and templates
Which of the following is the most rapid way of building documentation for an office visit note ?

[FS]
In which of the following tabs allow the user to add a portion of or the entire face sheet to the office visit note by clicking on one of more of the category icon ?

Peak flow rate
Which of the following is NOT one of the nine vital signs that appear by default in SpringCharts ?

Templates
Which of the following is a SpringCharts add-on feature that provide pre-built office visit notes, order, and letters, as well as pop-up text for specific specialties ?

( All of these)

– PMHX
– Problem List
– Previous Diagnosis

Selecting the [Dx] navigation tab produces a dialog window that allows the user to chose diagnoses from which of the following area?

40%
During the stage one of the Meaningful Use reporting period, what percentage of prescription were required to be transmitted electronically ?

Only the codes for the clinic’s common procedure are active.
Which of the following describes the procedure codes that are active in SpringCharts drop-down lists ?

Pending
Which of the following describes ordered test that have not yet been processed ?

Click [Report] button
Once the office visit note has been selected, how does a user create a report from the patient’s chart without opening the OV screen ?

A user not set up as a provider.
A prescription must be printed and manually signed if it is created in SpringCharts by which of the following individual ?

In the Tool menu within the OV screen
Which of the following describes the location of the H&P generator ?

Care Tree
Which of the following indicates the location of the H&P report once the user selects [Done] ?

Edit menu
Which menu in the OV screen provides quick access to the Face Sheet chart categories ?

Edit Menu
In which menu of the OV screen can a user access, view, or print a patient’s immunization ?

Action menu
In which of the OV screen provides access to features such as Lab, Diagnosis List, Immunization, Medication List, Procedures List, and Graph Vital Signs ?

Tool Menu
In which of the OV screen provides access to features such as H&P, Calculators, Care Plan, and Patient Instructions ?

Routing Slip
In which of the following features contain the procedure and diagnosis code and description that were selected in the office visit and are used for billing ?

Chart Tab
In which of the following features in the Tools menu in the OV screen enables the user to save existing office visit note under a different Care Tree tab that were it was originally saved ?

Evaluation & Management
Which of the following represented by E&M ?

The Evaluation & Management Coder
Which of the following recommends the current evaluation and management code for office visits ?

Insurance type
Which of the following is NOT a factor used to determine an E&M code ?

[Use Code]
Which of the following must a physician select if he/she wants to use the recommended code in the routing slip form ?

[Details]
Which of the following is selected to view the E&M Code Factors that were used to determine the specific recommendation code ?

[Send]
Which of the following will the user select to send the routing slip to the PMS interface ?

[Sign]
Which of the following would the provider select on the OV screen to lock and office visit ?

No one
If a provider locks an office visit note, who will have access to edit the note?

Addendum
Which of the following is a notation added to an office visit note after it has been permanently signed and locked ?

When the OV note was permanently signed and locked.
When will the option to add and addendum to an OV be available ?

It is never acceptable to code or bull for services not supported by documentation.
Which if the following describes the scenario when a clinician can code or bill for services not supported by the office visit note documentation ?

At the bottom of the existing note.
In which of the following location will the addendum to the office visit note appear once it is added ?

Multiple
How many addenda may be added to the same locked office visit note ?

Patient
Examination Reports detail the office visit note and are designed for which of the following ?

Both Report-Probs and Report-Recs
Which of the following pop-up text categories can be used to add text for further clarification in the examination report to the patient ?

Template Reports
Which of the following should user in the OV screen select from the Tools list to generate customized office visit reports ?

Any Patient
Customized templates created within a patient’s office visit note can be saved and then accessed and used for which of the following patients ?

[Done]
Which of the following option will automatically save the customized reports in the patient’s Care Tree ?

Coordination of Care
Which of the following comprises making available all resources to ensure healthcare providers have access to all required information on a patient’s condition and treatment and that the patient receives appropriate healthcare services ?

[F/U-Rem]
Which of the following navigation tabs allows a user to select a follow-up period and create reminder/referral notes ?

(all of these)

– Scheduling follow-up appointments
– Making a call.
– Setting reminders about labs or procedures.

Which of the following can administrative staff communicate with the team through the use of the ToDo/Reminder feature in the OV screen ?

[Send Later]
Which of the following will allow a reminder to be sent to another clinician on a future date ?

The OV window remains open behind the patient’s chart screen.
Which of the following describes what happens to the OV window when the user access the Edit Face Sheet window from OV window ?

[Test]
Which of the following navigation tabs will allow laboratory test to be order within the patient’s OV note?

Patient Name
When and excuse note is created within the OV screen, which of the following appears by default in the subject line of the New Excuse/Note window ?

None of these

(Procedure, Diagnosis, Medication List)

To view a patient’s previous laboratory results, the user should chose which of the following from the Action menu ?

(all of these)

– Validity of claim
– Policy coverage
– Reimbursement

Which of the following information can the insurance company determine from the documentation of procedures and diagnoses in the office visit note ?

Manually selecting the appropriate factor category and making necessary revisions.
Which of the following describes the manner in which provider may overrule the E&M Coder recommendation ?

HIPAA 837 MD
Which of the following is the HIPAA electronic claims form that generated by a physician ?

Patient and Physician
Office visit notes contain valuable information that is useful to which of the following parties ?

(All of these)

– Paper copy
– USB device
– Patient Portal

In which of the following format can patient receive clinical summaries of their office visits ?

12
Under the Template tab of the Office Visit Report Template Editor, the user can identify up to how many additional elements of the physical exam to include in a customized office visit report ?

blood presure
Which if the following would be documented under the Objective in S.O.A.P note format?

Assessment
In which of the following areas of the S.O.A.P notes will the user document the diagnosis of bacterial pneumonia ?

Sharing any protected health information describes here may violate HIPAA’s privacy ruling.

(Posting anonymously about a patient case on FB, Sharing details about a patient ultrasound (a family friend) with your spouse, or both)

Which of the following is an appropriate disclosure of protected health information ?

Right or Left options as selected in the Set User Preference window.
Which of the following determines how the Office Visit window orientation will appear to user ?

Pregnancy
Which of the following would NOT be documented under the Plan in a S.O.A.P note ?

Only after the patient’s chart is opened.
When can activities regarding a patient be documented in SpringCharts EHR ?

Head circumference
Which of the following is referred to with the abbreviation HC ?

(all of these)

– [Dx]
– [Rx]
-[Test]

Which of the following navigation tabs offers a search feature of the database instead of pop-up text ?

The program calculates the data from the patient measurements of height and weight.
Which of the following indicates why the BMI (body mass index) field is gray ?

( all of these)

– Previous immunizations
– Add past vaccines
– Print a copy of the immunization records

Which of the following can the user access or accomplish from the OV note without having to return to the patient’s chart ?

[Lab Test Graph]
Which of the following features in the OV screen allows the users to view an illustration of lab results and trends over time ?

Evaluation and Management Code
Which of the following is a five-digit number used by physicians to report the office visit encounter with a patient ?

Time indicated
If the time element for coordination of care and counseling is used to determine the E&M code, which of the following will be included as factors to support the code assigned ?

Not editable
When an office visit is permanently lock and signed, which dialog box will appear giving the user the option to add and addendum ?

( all of these)

– Date
– Time
– Initial

When an addendum is saved, which of the following stamps does the system automatically apply ?

Indicates the note is permanently signed and locked.
Which of the following is the purpose of the lock symbol next to office visit notes in the patient care tree ?

Review of System
Which of the following is represented by the abbreviation ROS ?

Present Illness
Which of the following is represented by the abbreviation PI ?

Template
Which of the following is a model document predesigned with a set

(all of these)

– Use fax cover sheet that displays confidentiality statement.
– Verify fax number before sending.
– Limit the information to that which minimally necessary.

Which of the following are considerations when faxing healthcare information ?

Electronic Signature Verified
Which of the following phrases notifies the pharmacy that the prescription was sent by the provider even though the prescription doesn’t display the digital signature ?

All of these are options that can be printed on a prescription.

(DEA number, NPI number, Diagnosis

In the prescription printing option window which of the following is NOT a choice to have printed on the prescription issued by a provider ?

(all of these)

– Allergies
– Sensitivities
– Routine Medication

Which of the following information saved in SpringCharts EHR enables the system to prevent adverse medication reactions by preforming drug-to-drug and drug-to-allergy checking ?

Third
The Drug Interaction and Allergy Checking icon is displayed as which button in the prescription text window ?

e-prescribing clearinghouse
When the user selects the Send Prescription Electronically icon at the bottom of the prescription window. The prescription passes through which of the following before reaching the pharmacy ?

Computerized Provider Order Entry
Which of the following is represented by CPOE ?

CPOE
Which of the following features enable physicians to document orders for labs, imaging studies, medical test, and medication in the patient’s electronic chart and maintain a records of the order ?

Less than 100
Physicians who write how many prescription during the 90-day reporting period for Meaningful Use are excluded from meeting the CPOE objective ?

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