Exam 11: The Health Record

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An aggregate of activities designed to ensure adequate quality is called quality control.

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Subjective information is that which the physician observes during the physical examination of the patient.

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A standard, nationwide rule must be followed in establishing a records retention schedule.

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When a patient is transferred from one facility to another, __________ of care ensures that no lapses in treatment occur and that transitions are smooth.

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Information picked up bit by bit is said to be __________.

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Entities considered essential or necessary are called __________.

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Remember that all backup systems need __________ to run.

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Continuity of care means

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A process of electronic data entry of medical practitioner or provider instructions for the treatment of patients is called _______________.

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The "R" entry in the SOAPER charting method means

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The EHR system should be backed up __________.

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How can the EHR function to best help improve a facility's appointment show rate?

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The type of electronic record of health-related information about an individual that can be created, gathered, managed, and consulted only by authorized clinicians and staff in a single healthcare organization is a(n)

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Medical facilities should keep records on minors for how long?

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What is the HIPAA privacy rule requirement for the retention of health records?

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For a record to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written. The best indication of this is the provider's signature or initials on the typed or EHR entry.

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When documents are added to a patient's chart, the most recent information should be placed on top.

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Reverse chronologic order is where the most recent item is on the top and older items are filed farther back.

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A filing system in which an intermediary source of reference, such as a card file, must be consulted to locate specific files, is called a(n) __________ system.

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The healthcare industry is one of constant __________, and the medical assistant is expected to stay abreast of current trends, laws, and requirements.

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