Chapter 2 Single Problem Visits

Question 1

1. What are date shortcuts for 2 days ago and 1 week from now?

Answer 1

1. t-2 and w+1

Question 2

2. How is working in an office visit encounter different than viewing a
   patient’s chart?

Answer 2

2. An office visit encounter offers activities such as Rooming and Plan (or
   a Visit Navigator) so you can document visit-specific information. A
   patient chart workspace allows you to view information in the patient’s
   chart, but not to document visit-specific information.

Question 3

3. True or False: To most efficiently completion match, enter the first few
   letters of the word you want to look up and then click the Selection
   button.

Answer 3

3. False (you should press ENTER).

Question 4

4. In the exam room, the nurse opens Lisa’s encounter. When done
   rooming the patient, what should the nurse do (assuming Dr. Lenite
   will be entering the exam room soon)? Why?

Answer 4

4. She should leave open Lisa’s workspace and secure the workstation so
   that when the provider logs in, the workstation automatically has Lisa’s
   workspace open.

Question 5

5. Can you document more than one reason for visit during a visit?

Answer 5

5. Yes

Question 6

6. Nurse Memphis looks up a chief complaint by typing “twisted ankle.”
   She selects that row and “ankle sprain” appears in the Reason for Visit
   field. Which one was the synonym: twisted ankle or ankle sprain?

Answer 6

6. Twisted ankle

Question 7

7. True or False: You should mark a medication as Not Taking if the
   patient is possibly allergic to it.

Answer 7

7. False

Question 8

8. What is the difference between an allergy being “Not on file” versus
   “No known allergies”?

Answer 8

8. Not on file means we’ve never inquired. No known allergies means the
   patient was asked but has no allergies.

Question 9

9. What keyboard technique should you use to move from field to field in
   the Vital Signs section?

Answer 9

9. TAB to go to the next field

Question 10

10. True or False: In the Medications section, you do not have to enter the
    name of a provider when documenting a patient-reported medication.

Answer 10

10. True

Question 11

11. For a results message to be sent, what status must nurse Denver mark a
    result in Enter/Edit Results?

Answer 11

11. Final

Question 12

12. Kristi informs nurse Denver that she received a seasonal flu shot at
    work last month. Explain how nurse Denver documents that fact.

Answer 12

12. In the Immunizations activity, open Single Historical Immunization and
    document the details.

Question 13

13. True or False: To enter dates for a series of historical immunizations,
    you should use a template.

Answer 13

13. True

Question 14

14. Dr. Quartz ordered a DTaP immunization. Nurse Memphis needs to
    document the details after giving the shot. In the Immunizations
    activity, what does the nurse click to open the details form?

Answer 14

14. Click Administer.

Question 15

15. True or False: Schedule folders listed under My Schedule are created
    by administrators.

Answer 15

15. False

Question 16

16. Dr. Quartz entered into the Progress Notes section some detailed advice
    about how the patient can take care of his lower back pain. Where
    should Dr. Quartz have documented this? Explain why.

Answer 16

16. Dr. Quartz should have used the Patient Instructions section so it could
    be printed on an After Visit Summary for the patient to take home.

Question 17

17. True or False: To enter an LOS code for the visit, you must use an LOS
    button.

Answer 17

17. False

Question 18

18. Nurse Madison created a personalized schedule folder and decides that
    she wants to remove a column from the display. What button should he
    click: Create, Properties, or Remove?

Answer 18

18. Properties

Question 19

19. What detail about a medication makes it “current”?

Answer 19

19. Its end date is still in the future.

Question 20

20. Explain the difference between an expired medication and a
    discontinued medication.

Answer 20

20. An expired medication is one that has passed its end date, whereas a
    discontinued medication is one that a clinician has chosen to end by
    entering a new end date of today.

Question 21

21. In Meds & Orders, Dr. Quartz is in the Order Composer for a blood
    test. He wants to change it so that the order will be released to its
    destination two weeks from now. What should he do?

Answer 21

21. Set the Status to Future.

Question 22

22. Complete these statements: Use the Dose field to enter how ______
    medication should be taken. Use the Frequency field to document how
    _______ this medication should be taken.

Answer 22

22. much, often

Question 23

23. Name one possible reason a medication warning will appear.

Answer 23

23. One possible reason: Patient is allergic to the medication being ordered.

Question 24

24. True or False: If nurse Denver does not have security to sign orders,
    then that means she cannot look up orders.

Answer 24

24. False

Question 25

25. Every time Dr. Granite orders a certain medication, a sig that she doesn’t want is listed. Describe what she can do so that the next time she orders it, the sig that she wants will appear.

Answer 25

25. Add it to her user preference list: Click the star next to the pended medication. In the window, change details as needed and save it.

Question 26

26. Richard needs to come in every three months for a TSH test. What status should that order be?

Answer 26

26. Standing

Question 27

27. True or False: If the order Dr. Mica selected has an advised (recommended) question asking if the patient is pregnant, she can sign the order without answering it.

Answer 27

27. True

Question 28

28. Dr. Lenite just signed an order for a glucose test, and realized that it was the wrong test. Describe one way she can cancel this order.

Answer 28

28. Find the test at the bottom of Meds & Orders, and click Cancel.

Question 29

29. What visual cue tells you that a medication is expired?

Answer 29

29. It appears with a strikethrough.

Question 30

30. Which symbol means this signed medication will be visible in the MAR: house or bed?

Answer 30

30. Bed

Question 31

31. Kristi’s asthma medication is expired, but it’s listed in the Medications section, which should only show current medications. Why is it appearing there?

Answer 31

31. It is marked long-term.

Question 32

32. Dr. Mica is working in Meds & Orders and notices that Harold’s statin prescription is nearing its end date. To quickly order more, what should Dr. Mica do?

Answer 32

32. Click Reorder

Question 33

33. Dr. Lenite is working in the Medications section and when she asks Kristi about her reflux medication, Kristi says she doesn’t want to take it anymore and she threw it away. Can Dr. Lenite discontinue that medication in the Medications section?

Answer 33

33. Yes (red X)

Question 34

34. True or False: To associate orders with diagnoses, use the Visit Diagnoses section.

Answer 34

34. False

Question 35

35. You saw a patient yesterday and wrote part of your progress note. You exited the workspace. Now you want to finish the note. When you attempt to open the patient’s encounter, you’re not prompted to create an addendum. Why?

Answer 35

35. You had exited the workspace, so the encounter is still open. You’re only prompted to create an addendum if the encounter is closed.