Deck 11: The Health Record

Question 1

Which of the following is not needed when describing a patient's chief complaint?

A) Remedies the patient has tried to relieve symptoms
B) The duration of pain
C) The time when symptoms were first noticed
D) How many family members are healthy

Answer 1

How many family members are healthy

Question 2

Many healthcare facilities now use voice recognition software for transcription. The system can be used to dictate which types of reports?

A) Progress notes
B) Letters
C) E-mails
D) All of the above

Answer 2

All of the above

Question 3

Which statement is not accurate about correcting charting errors?

A) Insert the correction above or immediately after the error.
B) Draw two clear lines through the error.
C) In the margin, initial and date the error correction.
D) Do not hide charting errors.

Answer 3

Draw two clear lines through the error.

Question 4

Which of the following are common types of filing equipment found in a medical office?

A) Rotary circular files
B) Lateral files
C) Automated files
D) All of the above

Question 5

How would you properly index the name "Amanda M. Stiles-Duncan" for filing?

A) Stilesduncan, Amanda M.
B) Stiles Duncan, Amanda M.
C) Duncanstiles, Amanda M.
D) Duncan, Amanda M. Stiles

Question 6

The most frequently used follow-up method is a

A) tickler file.
B) transitory file.
C) practice management file.
D) None of the above

Question 7

Who is the legal owner of the information stored in a patient's record?

A) The patient
B) The physician or agency where services were provided
C) The patient's insurance company
D) Both the patient and the physician

Question 8

Continuity of care means

A) an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries.
B) a formal examination of an organization's or individual's accounts.
C) medical attention that continues smoothly from one provider to another so that the patient receives the most benefit.
D) granted or endowed with a particular authority.

Question 9

Medical facilities should keep records on minors for how long?

A) Indefinitely
B) Until the minor is deceased
C) For 10 years
D) Until the minor reaches the age of majority, plus 3 years

Question 10

Information that is gained by questioning the patient or that is taken from a form is called ________________ information.

A) confidential
B) subjective
C) objective
D) necessary

Question 11

Which statement is not true regarding the reasons for keeping accurate medical records?

A) The medical record provides critical information for other caregivers.
B) Effects of various treatments can be tracked and statistics gleaned from them.
C) The patient's family may want to examine the records and correct errors.
D) Accurate records are vital for financial reimbursements.

Question 12

Which of the following is not an advantage of color-coded filing systems?

A) Patient charts can be found quickly.
B) It is easy to tell when a file has been misplaced.
C) Patient charts can be re-filed quickly.
D) All of the above are advantages.

Question 13

Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files.

A) inactive
B) closed
C) active
D) dead

Question 14

How would you properly index the name "Jill Freeman, M.D." for filing if you had another patient with the same name but without the title?

A) Dr. Jill Freeman
B) Freeman, Dr. Jill
C) Freeman, Jill
D) Freeman, Jill M.D.

Question 15

Which of the following is not a method of organizing a medical record?

A) Source oriented
B) Problem oriented
C) Progressively
D) Chronologically

Question 16

What is the most important reason for telling the physician when a charting error is discovered later?

A) To protect the patient's health and well-being
B) To protect the medical assistant's job
C) To make sure the medical assistant is not accused of making the error
D) To keep the patient from discovering the error

Question 17

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

A) shelf filing
B) indirect filing
C) direct filing
D) shingling

Question 18

Which of the following is not an advantage of a numeric filing system?

A) It allows periodic expansion without shifting folders.
B) It provides additional confidentiality to the chart.
C) Filing activity is greatest when the system is initiated.
D) It saves time in record retrieval and re-filing.

Question 19

The medical record should be released only with a

A) verbal order from the physician.
B) written order from the physician.
C) written release from the patient.
D) verbal order from the office manager.

Question 20

Which of the following is not objective information?

A) Progress notes
B) Family history
C) Diagnosis
D) Physical examination and findings

Question 21

A set of physical properties, the values of which determine characteristics or behavior, is called

A) interoperables.
B) parameters.
C) informatics.
D) gauges.

Question 22

A correction to a medical record can be made by

A) drawing a line through the entry and writing the correct information.
B) whiting out the entry and writing over it.
C) rewriting the entire page of progress notes with the error corrected.
D) All of the above

Question 23

The medical assistant should consider which of the following when selecting filing equipment?

A) Fire protection
B) Cost of space and equipment
C) Confidentiality requirements
D) All of the above

Question 24

The "E" entry in the SOAPER charting method means

A) entry.
B) evaluation.
C) education.
D) exclude.

Question 25

Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to

A) make frequent eye contact with the patient and smile.
B) type in every word the patient says.
C) make sure the patient is not hiding any part of the health history.
D) sit in a chair across from the patient so that the person cannot see the screen.

Question 26

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)

A) PHR.
B) EHR.
C) EMR.
D) PHI.

Question 27

Who ultimately decides whether a medical record can be released?

A) The physician
B) The office manager
C) The medical assistant
D) The patient

Question 28

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

A) The system can matrix the schedule with input from a staff member.
B) The system can be programmed to initiate reminder and confirmation calls to patients.
C) The system will allow searches for patient appointments based on a few parameters.
D) The system can generate a list of the confirmed appointments.

Question 29

Disadvantages of the EHR system include

A) cost.
B) training time.
C) learning curve.
D) All of the above

Question 30

The process of moving an active file to inactive status is called

A) purging.
B) indexing.
C) coding.
D) conditioning.

Question 31

The "R" entry in the SOAPER charting method means

A) rationale.
B) response.
C) repeat.
D) reinforce.

Question 32

HIPAA recommends that physicians keep the records on patients for at least

A) 1 year.
B) 2 years.
C) 3 years.
D) HIPAA does not recommend a number of years.

Question 33

The newest component used today to complete transcription and authenticate records is __________ software.

A) voice-activated
B) voice recognition
C) voice registry
D) voice-controlled

Question 34

Advantages of the EHR system include

A) ability of the physician to see more patients in a day.
B) cost of implementation.
C) possibility of a breach of confidentiality.
D) concern of patients over privacy.

Question 35

The physical medical record belongs to the

A) patient.
B) physician or provider.
C) insurance company.
D) All of the above

Question 36

How are corrections made to the electronic health record?

A) Corrections can be noted by hand and entered, as long as they are initialed.
B) A new entry or addendum must be added close to the original entry with the correct information and then initialed.
C) The incorrect entry is deleted and the new one is written in.
D) The error is brought to the attention of the office manager for instructions on how to correct it.

Question 37

The advantages of using the color-coding filing system are the following:

A) a misfiled record is easily spotted even from a distance.
B) the use of color visually restricts the area of search for a specific record.
C) you can use either the alphabetic or numeric color-coding system.
D) All of the above

Question 38

A strong, highly glazed composition paper or heavy card stock is called

A) augment.
B) pressboard.
C) microfilm.
D) shingle.

Question 39

The type of electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization is a(n)

A) EMH.
B) EHR.
C) EMR.
D) PHI.

Question 40

The preferred filing method for a physician's office is

A) alphabetic.
B) numeric.
C) alphanumeric.
D) the one most preferred by the staff.

Question 41

__________ information is observed by the physician.

Question 42

In most cases, does the electronic health record system require more or less storage space than a paper filing system?

A) More
B) Less
C) About the same

Question 43

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.

A) Both statements are true.
B) Both statements are false.
C) The first statement is true; the second is false.
D) The first statement is false; the second is true.

Question 44

The concise account of the patient's symptoms in his or her own words is the __________.

Question 45

Medical assistants can encourage other staff members during a conversion to an electronic health record system by

A) assisting whenever possible as co-workers perform their duties.
B) welcoming a call for help if asked to provide assistance.
C) working as a team to help clarify confusing technical instructions.
D) All of the above

Question 46

What is one of the benefits of using a paper health record?

A) Multiple users can access the record at the same time
B) Fewer errors
C) Good evidence of patient care
D) Links clinical information for billing purposes
E) All of the above

Question 47

Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology?

A) Appointment scheduler
B) Charge capture
C) Referral management
D) Medical billing system

Question 48

To make greater, more numerous, larger, or more intense is to __________.

Question 49

__________ of an entry in a medical record is never acceptable.

Question 50

Which of the following indirect filing systems is used by a majority of large clinics and hospitals?

A) Alphabetic filing
B) Numeric filing
C) Subject filing
D) Color-coded filing

Question 51

Who is responsible for calming patients' fears and concerns about switching to an electronic medical record system?

A) The physician
B) The front office medical assistants
C) The back office medical assistants
D) The entire team at the office

Question 52

Improved outcomes is part of which of the stages of meaningful use?

A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4

Question 53

__________ information is provided by the patient.

Question 54

Which of the following health information exchanges allows providers to find and/or request information on a patient from other providers?

A) Direct exchange
B) Query-based exchange
C) Consumer mediated exchange
D) All of the above

Question 55

To be granted or endowed with a particular authority or right is to be __________.

Question 56

In a paper record, which of the following is never an acceptable method of correction to a handwritten entry?

A) Draw a line through the error.
B) Erase or use a correction fluid.
C) Insert the correction above the error.
D) Write initials or signature below the correction and date.
E) All of the above are acceptable.

Question 57

Which section of the law, commonly known as the Economic Stimulus Package, pertains to healthcare?

A) ARRA
B) HITECH Act
C) HIPAA
D) None of the above

Question 58

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

Question 59

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

A) HIPAA does not include requirements.
B) Records must be kept for at least 10 years.
C) For at least the period of the statute of limitations for medical malpractice claims
D) Until the minor reaches the age of majority plus the statute of limitations

Question 60

Which EHR system backup is probably the least trouble and requires the least amount of hardware?

A) Online backup system
B) External hard drives
C) Full server backup
D) Thumb drive backup

Question 61

Perhaps the most difficult obstacle to overcome is the __________ of employees in physicians' offices who dislike change.

Question 62

The __________ diagnosis is temporary and is made before test results have been received.

Question 63

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

Question 64

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

Question 65

The type of record that is created from more than one healthcare organization and can be managed and consulted by licensed clinicians and staff from those organizations who are involved in the patient's care is an electronic __________ record.

Question 66

Deciding where to file a particular chart based on the patient's name is called __________.

Question 67

A(n) __________ is made of heavy paper stock and is used to replace an entire folder that has been temporarily removed from its proper place.

Question 68

Entities considered essential or necessary are called __________.

Question 69

A filing system that uses a combination of letters and numbers is said to be __________.

Question 70

Any of a set of physical properties, the value of which determines characteristics or behavior, is called a(n) __________.

Question 71

The type of record created by an entity that is a single organization involved in the patient's care is an electronic __________ record.

Question 72

The EHR billing system can perform online insurance __________ and can capture demographic data.

Question 73

The EHR system's __________ component allows the physician's staff to communicate with and send claims electronically to insurance companies.

Question 74

The business care and prudence expected from a person seeking to satisfy a legal requirement under similar circumstances is called ________________.

Question 75

A filing system in which materials can be located without consulting an intermediary source of reference is said to be a(n) __________ system.

Question 76

Additional training on the EHR system is needed to run it at full __________.

Question 77

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.

Question 78

A(n) __________ file is a follow-up system used to help the medical assistant remember when a certain task needs to be done.

Question 79

A(n) __________ schedule is a plan for keeping and purging medical records.

Question 80

Most experts agree that the EHR system will help reduce medical __________.