VISIT NOTES QUIZ 1. In the Examination section of the visit note template, how would you quickly mark all sections of the exam as normal? A. Select (-) at the top of the template B. Select the negative box for each item in the template C. Individually select each system, then select the negative box for each item 2. After marking all sections of the exam as normal, how would you changev the General Appearance section to note a specific item? A. Cannot change General Appearance if you mark all as normal B. Select the positive box next to General Appearance and then select items from the template C. Select the words General Appearance and then select items from the template 3. How would you note only that the patient is oriented to person, place and time? (If there is no neurologic exam in your visit note, or you do not perform a neurologic exam please disregard.) A. Select the negative box for Neurologic in the template B. Select Unchanged in the template C. Select Neurologic, then Higher Functions, then Orientation, then mark the positive boxes for person, place and time 4. While conducting the musculoskeletal examination you want to add an observation that is unique to the patient and not found in the selection list, how can this be done? A. Only items shown in the template can be added to the visit note B. Select Musculoskeletal, then select Other, then type the observation into the text box C. Print the visit note and write the observation in the Musculoskeletal section
5. How do you markup and insert an image into the examination section of the visit note? A. Select Musculoskeletal, then select Image B. Select Image from the right side column, select Examination from the drop-down box, select the desired image from the second drop-down box, then use the drawing tools C. An image cannot be inserted into the visit note 6. How do you enter height, weight and blood pressure readings for the patient? A. Select Vital Signs from the template and then enter the data in the appropriate field B. Type the data into a text box C. Select Vital Signs from the Examination template, then select Other 7. How would you calculate the patient's BMI? A. Use a calculator and then enter the results into the Examination template B. IMS automatically calculates BMI when height and weight are entered C. BMI cannot be shown in the visit note 8. The patient has brought in blood sugar readings that they have taken at home, how do you enter these into the note? A. Enter the data into the Vital Signs template in the Blood Sugar field B. Enter the data in the Medical History template C. From the Vital Signs form, select Taken by Patient from the right column, then enter the data into the appropriate fields or if an interface has been setup, the data can be read directly from a glucose meter
9. This visit is routine, most of the information that is required in the visit note is identical to what was entered in a previous visit note for the patient, how can data from a previous visit note be quickly added to the current visit note? A. Open a previous visit note from the patient's chart, then select the same information in the template B. Select Copy From Prv. Visit from the right side column, choose the data to copy from the list, select the Copy button C. Open the previous visit note and change the date 10. This visit is a common visit type for many patients, most of the information to be entered is common among the patients so has been stored in Global Template, how do you quickly access the global template to pull into today s visit? A. Select Copy From Template from the right side column, select the appropriate template, choose the data to copy from the list and select the Copy button B. Open a visit note for a similar patient and change the patient name C. You must create the visit note from scratch each time
11. How would you add a new diagnosis to the note? A. Type the diagnosis code into the note B. Enter the code in the Diagnosis or Assessment section from the left panel. C. Diagnosis codes need to be added to IMS each time that you need to select one 12. How do you search for a diagnosis in the Diagnosis Template? A. You must know the ICD9 code for each diagnosis B. Select the Search New button from the diagnosis template, search by description or code C. Select the Add to Dx button 13. A list of the patients active diagnoses appears at the bottom of the Diagnosis window. How would you select one of the existing diagnoses in the list to be applied for use in this visit? A. Select the Add button from the This Visit tab B. From the Active Diagnosis tab, select the icon in the S column for the appropriate diagnosis C. You must re-enter the diagnosis
14. How would you note the severity of a particular diagnosis in the Active Diagnosis list? The progress? A. Select the Add ICD Template button B. Select the Full List button C. From the Active Diagnosis tab, choose the appropriate items in the drop-down lists to the right of the diagnosis 15. How is one way that you would add a new prescription to the visit note? A. Select the Prescription template, choose a drug from a category or search for a drug. B. Double left click on the drug in the Active Prescription list C. Enter it through the Current Medications tab 16. From the visit note, how would you print the prescription? fax it? E-Send it? A. In the Prescription template select the Rx History button B. In the Prescription template, create the prescription, then select the Fax/Print/e-send button and then select from the list C. Prescriptions cannot be sent from the visit note. This must be done at checkout 17. The patient's current medications are listed in the Prescription Template, how would you check for drug interaction? A. Open a web browser window and use Google to search for interaction issues B. Double left click on a drug in the list C. Select the Drug Checking icon in the template 18. How would you discontinue a current medication from the list of patient s medications? A. Select the drug and then select the Delete button B. Select the drug and the select the DC button C. Remove the drug from the Setup screen
19. How would you approve a refill from the visit note? A. From the Prescription template, select the appropriate drug, then select the Approve Refill button and follow the prompts B. Go through the steps to prescribe it as a new drug C. Refills cannot be approved from within the visit note, it must be done from chart view 20. Where in the visit note can a lab or diagnostic order be added? A. The Prescription template B. The Procedures template C. The Diagnostic/Lab template 21. How would you add a careplan/patient education to be printed for the patient? A. Type the careplan into the note B. Add it from the Plan template C. Select it from the careplan/patient education template 22. How do you create the super bill for the patient from within the visit note? A. From either the Super Bill template or Super Bill in the right column select the appropriate CPT codes and add them to the list B. Close the visit note and open the Check In/Out window to enter the superbill C. The biller must create a super bill 23. You would like to view a document regarding the current patient, how can you do this from within the visit note? A. Select Print from the right column, select the document, then select the View button B. Select the View template C. Select Document from the right column, select the appropriate document from the list, then select the View button
24. You would like to fax a copy of the current visit note to the referring doctor, how can this be done from within the visit note? A. This cannot be done from within the visit note B. You can only fax previous visit notes C. Select Fax from the right column, select Today's Visit, select who you would like to fax to, then select the Fax button 25. You want the patient to return in 2 weeks for a follow-up visit, how do you enter this in the note so that the front desk will know this and will be able to quickly schedule the next visit when checking out the patient? A. Print out the visit note and write the follow-up appointment on it B. Select Follow Up from the right column, fill in the information and select OK C. Enter follow up information in the Sign Off screen D. Enter follow up information in the plan section 26. How can you enter a private note that will not be displayed in the visit note? A. Select Other in the Examination template and type the note B. Do not enter any information that you do not want the patient to see C. Select Private Note from the right column and then enter the information 27. From within the visit note, how can you send a message to the front desk to call the patient in 3 weeks to schedule another appointment? A. Select Reminder from the right column, then create a reminder and assign it to the front desk personnel B. Tell the patient to ask for an appointment while checking out C. Select Note from the right column, then type in the desired information 28. How do you sign-off from within the visit note? A. Print the visit note, then sign in the provided space B. Select Show Link B. Select Sign Off from the right column, then select Use Existing Password