Deck 6: Organization, Storage, and Management of Health Records

Question 1

An example of a "loose sheet" or a document that may need to be added to a chart at a later time is a:

A) letter from another clinic.
B) discharge summary.
C) consultation report.
D) lab report.
E) All of the above

Answer 1

All of the above

Question 2

To minimize and detect filing errors, labels are often:

A) highlighted.
B) color-coded.
C) flagged.
D) removed.
E) replaced.

Answer 2

color-coded.

Question 3

Information stored on the electronic health record can be organized and displayed in a variety of ways because databases store records in a method called:

A) random access.
B) remote access.
C) relative access.
D) reporting access.
E) retrieval access.

Answer 3

random access.

Question 4

Systems that use both paper and electronic records are called:

A) double health records.
B) secondary health records.
C) hybrid health records.
D) level one health records.
E) joint health records.

Question 5

Which of the following is a method of organizing a patient chart according to the source of the document?

A) Problem-oriented medical record
B) Integrated record
C) Source-oriented medical record
D) Office-oriented medical record
E) Physician-oriented medical record

Question 6

A filing method in which charts are filed in ascending numeric order is:

A) alphanumeric filing.
B) terminal digit filing.
C) straight numeric order filing.
D) middle digit filing.
E) alphabetic filing.

Question 7

A document that serves as an index to a problem-oriented medical record is a(n):

A) review of systems.
B) history and physical.
C) problem list.
D) chart note.
E) review sheet.

Question 8

A(n) ________ intermingles documents from various sources and is arranged sequentially by date.

A) problem-oriented medical record
B) source-oriented medical record
C) office-oriented medical record
D) date-oriented medical record
E) integrated medical record

Question 9

All of the following are advantages of the integrated chart method EXCEPT:

A) it is easier to add more pages to the chart.
B) the most recent progress notes are on top.
C) the most recent notes are probably the most relevant.
D) it is easy to review the most recent visit.
E) you must know the date of a particular item or look through the entire medical record.

Question 10

Which of the following is a numbering system in which a new number is assigned for each admission or ED visit?

A) Unit numbering
B) Serial-unit numbering
C) Family numbering
D) Serial numbering
E) Admission numbering

Question 11

Which of the following is a method of organizing a patient chart by diagnosis or medical problem?

A) Problem-oriented medical record
B) Integrated record
C) Source-oriented medical record
D) Office-oriented medical record
E) Physician-oriented medical record

Question 12

A filing method that uses the middle set of numbers as the primary set for filing is:

A) alphanumeric filing.
B) terminal digit filing.
C) straight numeric order filing.
D) middle digit filing.
E) alphabetic filing.

Question 13

In a color-coded filing system, a misfiled chart will easily stand out because there will be a break in the visual color pattern sequence.

Question 14

Electronic health records present information in a format similar to paper health records.

Question 15

A patient medical record number is unique to that patient.

Question 16

Medical record filing methods are:

A) alphabetic.
B) numeric.
C) colored.
D) Both A and B
E) Both B and C

Question 17

The goal of a filing method is:

A) easy detection of misfiled or missing charts.
B) quick filing of charts.
C) easy expansion.
D) quick chart retrieval.
E) All of the above

Question 18

A filing method that uses the last set of the hyphenated record number as the primary set of numbers for filing is:

A) terminal digit filing.
B) middle digit filing.
C) straight numeric order filing.
D) alphanumeric filing.
E) All of the above

Question 19

The electronic health record can display patient data in which of the following formats?

A) Source-oriented medical record
B) Problem-oriented medical record
C) Integrated record
D) Any way requested
E) All of the above

Question 20

All of the following statements are true of an alphabetic filing system EXCEPT:

A) it is a difficult system to learn.
B) misfiles can occur easily.
C) alphabetic systems grow unevenly.
D) alphabetic systems require frequent reorganization.
E) charts can be located knowing only the patient name.

Question 21

Cataloging documents as the wrong type is called:

A) improper barcoding.
B) improper abstracting.
C) improper batching.
D) improper coding.
E) None of the above

Question 22

According to OSHA, the aisle between filing or shelving units must be at least ________ feet wide.

A) 1
B) 2
C) 3
D) 4
E) 5

Question 23

A second chart may be started for a patient when:

A) the original chart cannot be located.
B) the patient changed names through marriage or divorce.
C) the patient name is not found in the master patient index.
D) serial or serial-unit numbering is used and the previous record was not brought forward.
E) All of the above

Question 24

A report listing items missing from the chart is a(n):

A) missing report list.
B) deficiency list.
C) provider information list.
D) medical record abstract.
E) itemized report list.

Question 25

Which of the following is a numbering system in which a medical record number is assigned the first time a patient is registered and is used every time a patient returns?

A) Unit numbering
B) Serial-unit numbering
C) Family numbering
D) Serial numbering
E) Admission numbering

Question 26

The length of time that records are kept depends on:

A) state law.
B) contract obligations.
C) age of the patient.
D) policies of the facility.
E) All of the above

Question 27

Paper medical records are usually destroyed by:

A) shredding.
B) incinerating.
C) recycling.
D) Both a and b
E) Both a and c

Question 28

Which of the following is NOT a measure that can be taken to maintain the security of patient records?

A) Chemical or halogen fire extinguishers in the record room
B) Access to files by all employees at all times
C) Locks for filing cabinets and/or doors
D) File rooms on the second floor or higher in areas prone to flooding
E) Sprinklers in file rooms

Question 29

A computer program in document imaging systems that associates various ID fields and keywords with scanned images is called:

A) cataloging the data.
B) cataloging the image.
C) cataloging the field.
D) cataloging the information.
E) cataloging the patient.

Question 30

All of the following statements are true of unit numbering EXCEPT:

A) the Joint Commission recommends that unit numbering be used.
B) there is one single medical record.
C) there is one medical record number assigned.
D) most ambulatory care and inpatient facilities use unit numbering.
E) All of the above statements are true.

Question 31

Which of the following duties is NOT included in "prepping" the chart?

A) Staples and paperclips are removed.
B) All documents are verified as belonging to the patient.
C) Barcoded divider sheets are printed and inserted between groups of pages.
D) Information to be scanned is sent to primary physician for signature.
E) Pages are examined and batched in correct order.

Question 32

One form of archiving is:

A) copying the chart.
B) microfilming the chart.
C) reviewing the chart.
D) thinning the chart.
E) None of the above

Question 33

The first step to ensure the record is complete and accurate is to:

A) analyze the record for deficiencies.
B) make sure all items requiring signatures are signed.
C) abstract the record.
D) code the record.
E) file the record.

Question 34

A paper or plastic placeholder that indicates a chart has been removed is a(n):

A) routing guide.
B) filing guide.
C) requisition slip.
D) chart request.
E) outguide.

Question 35

How many pages does AHIMA estimate one inpatient stay contains on average?

A) 10
B) 25
C) 50
D) 75
E) 100

Question 36

Quality control is most important during:

A) scanning and cataloging.
B) storage.
C) transporting.
D) shredding.
E) retrieval.

Question 37

It is the responsibility of the ________ to ensure each patient is assigned a unique chart number.

A) HIM department
B) billing department
C) nursing department
D) IT department
E) risk management department

Question 38

Selecting the patient files that are least likely to be needed and storing them in another place or format is called:

A) remoting.
B) archiving.
C) inactivating.
D) All of the above
E) None of the above

Question 39

The electronic health record will eventually eliminate all paper.

Question 40

X-ray films and other radiology records not stored electronically are often stored in:

A) medical records.
B) jackets.
C) bins.
D) drawers.
E) boxes.

Question 41

When medical records are used for legal purposes, it is important that both sides receive identical copies.

Question 42

Healthcare facilities are required to keep track of any disclosure of patient information. These disclosure records are kept for at least ________ years.

A) 2
B) 3
C) 4
D) 6
E) 10

Question 43

The AHIMA Code of Ethics serves which of the following purposes?

A) It provides ethical principles by which the public can hold HIM professionals responsible.
B) It helps HIM professionals identify relevant considerations when professional obligations conflict or ethical uncertainties arise.
C) It provides core values on which the HIM mission was based.
D) It socializes new practitioners to the field to HIM's mission, values, and ethical principles.
E) All of the above

Question 44

Which of the following is NOT an ethical principle based on core values of AHIMA?

A) Participate in unethical practices or procedures
B) Recruit and mentor students
C) Put service and the health and welfare of persons before self-interest
D) Represent the profession accurately to the public
E) Advocate, uphold, and defend the individual's right to privacy

Question 45

Alleged violation of the AHIMA Code of Ethics is subject to a(n):

A) peer review process.
B) committee interpretation.
C) automatic revocation of credentials.
D) automatic loss of membership.
E) probationary period.

Question 46

The AHIMA Code of Ethics does all of the following EXCEPT:

A) offer ethical guidelines to which professionals aspire.
B) provide guidelines for ethical and unethical behavior.
C) offer ethical guidelines by which a professional's actions can be judged.
D) set forth values and ethical principles.
E) specify the values, principles, and guidelines that are the most important.

Question 47

HIPAA regulations require the ________ authorization to release health information.

A) provider's
B) patient's
C) HIM manager's
D) Both a and b
E) Both a and c

Question 48

Ethical obligations of the HIM professional do NOT include:

A) protection of patient privacy.
B) disclosure of information.
C) quantity of information.
D) development of health information systems.
E) maintenance of health information systems.

Question 49

Professional standards by which health information professionals conduct themselves are called:

A) standards.
B) obligations.
C) ethics.
D) contracts.
E) codes.

Question 50

Professional values require an individual to put aside personal values.