Deck 19: The Health Record

Question 1

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.

Answer 1

The patient's family may want to examine the records and correct errors.

Question 2

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.

Answer 2

HIPAA does not recommend a number of years.

Question 3

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 the statute of limitations

Answer 3

Until the minor reaches the age of majority, plus the statute of limitations

Question 4

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

Question 5

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 6

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 7

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 8

Which of the following is not objective information?

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

Question 9

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

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

Question 10

Continuity of care means

A) a collection 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 11

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

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

Question 12

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 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

A filing system that requires the use of alphabetic cross-reference to locate specific files is called a(n) _____________ system.

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

Question 15

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 16

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 17

The physical medical record belongs to the

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

Question 18

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

Question 19

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

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

Question 20

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 21

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

A) social history
B) history of present illness
C) chief complaint
D) diagnosis

Question 22

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 23

A rule that controls how something is done, is called

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

Question 24

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 25

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

A) differential
B) provisional
C) Both A and B
D) None of the above

Question 26

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 27

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 28

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 29

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 30

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 31

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 32

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

A) terminal digit
B) numeric
C) alphabetic
D) alphanumeric

Question 33

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

A) vested
B) involved
C) endowed
D) None of the above

Question 34

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 35

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 36

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 37

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 38

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

A) Correction
B) Obliteration
C) Addendum
D) All of the above

Question 39

An electronic record of health-related information that can be drawn from multiple sources and is managed, shared, and controlled by the individual is a

A) EHR.
B) EMR.
C) PHR.
D) None of the above

Question 40

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 41

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

A) errors
B) confusion
C) upkeep
D) space

Question 42

A process to ensure the reliability of test results often using manufactured samples with known values is known as

A) parameter.
B) interface.
C) compliance.
D) quality control.

Question 43

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 44

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

A) direct
B) indirect
C) progressive
D) retention

Question 45

The type of medical record organization that has observations and data categorized in sections such as; provider, laboratory, radiology, hospital, and consultations.

A) Source-oriented
B) Problem-oriented
C) Alphabetic
D) Reverse-chronologic

Question 46

The EHR system should be backed up __________.

A) hourly
B) daily
C) weekly
D) monthly

Question 47

Charge capture relates to charges for missed appointments.

Question 48

The software of an EHR system can be designed to be compatible with a medical specialty office, such as pediatrics or oncology.

Question 49

The EHR system is not capable of telling whether a certain procedure matches a specific diagnosis code.

Question 50

Information contained in an electronic health record usually can be accessed from several different physical places.

Question 51

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

A) medical billing
B) charge capture
C) eligibility verification
D) All of the above

Question 52

Using EHRs for e-prescribing and CPOE will meet the requirements of

A) HIPAA.
B) Affordable Care Act.
C) meaningful use.
D) OSHA.

Question 53

The type of medical record organization that has the following four components; database, problem list, treatment plan, progress notes.

A) Source-oriented
B) Problem-oriented
C) Alphabetic
D) Reverse-chronologic

Question 54

Very little statistical information can be gleaned from an EHR system.

Question 55

The patient portals can allow patients to set their own appointments using the internet.

Question 56

PHI stands for

A) private health information.
B) past health information.
C) protected health information.
D) None of the above

Question 57

A process of electronic data entry of the provider's instructions for the treatment of patients is called _______________.

A) EMR
B) PHI
C) CPOE
D) All of the above