Deck 26: The Medical Record,documentation,and Filing

Question 1

What does the P in SOAP stand for?

A) physician,provider,or medical practice
B) patient
C) plans for further studies,treatment,or management
D) preventive care

Answer 1

plans for further studies,treatment,or management

Question 2

A HIPAA Security Rule audit includes a review of all but which of the following categories?

A) drug authorizations
B) physical safeguards
C) technical safeguards
D) administrative safeguards

Answer 2

drug authorizations

Question 3

When recording progress notes,the specific chief complaint should be:

A) a paraphrased description of the patient's condition
B) written using the patient's own words
C) a series of codes that correlate to a list of common symptoms
D) recorded only by the physician or provider

Answer 3

written using the patient's own words

Question 4

A complete and accurate medical record provides legal protection for:

A) patients
B) physicians
C) both patients and physicians
D) neither patients nor physicians

Question 5

Which of the following is an objective statement?

A) You don't look well.
B) Mrs.Smith says her mouth feels dry.
C) I have a headache.
D) The patient's heart rate is elevated at 120 beats per minute.

Question 6

Lab reports should be filed in _____ in a separate section of the patient chart.

A) alphabetical order
B) order of relevance
C) chronological order
D) order of importance

Question 7

It is recommended that filing dividers or guides be constructed of _____ material.

A) heavy,sturdy
B) light,flexible
C) transparent,flexible
D) sturdy,magnetic

Question 8

Most filing systems are based directly or indirectly on a(n)_____ arrangement.

A) chronologic
B) alphabetical
C) geographic
D) subject

Question 9

When the patient's paper chart is opened flat,which of the following is typically found on the right side?

A) progress notes
B) medication list
C) patient data
D) immunization records

Question 10

In regards to filing,_____ is done by marking the index identifier on the paper to be filed.

A) indexing
B) sorting
C) storing
D) coding

Question 11

What do the two Ds in CHEDDAR stand for?

A) details and drugs
B) drug to drug
C) details and documentation
D) dosages and documentation

Question 12

The ____ is generally the first person to inspect reports.

A) patient
B) insurance company
C) medical assistant
D) provider

Question 13

When filing records in a new file cabinet,it is recommended that you:

A) space out files evenly in all drawers
B) place files in the middle drawers first
C) place files in the top drawer first
D) place files in the bottom drawers first

Question 14

Which of the following is not an advantage of EHRs?

A) They facilitate coordination of care among providers.
B) They completely eliminate the necessity for paper records.
C) They can assign CPT and ICD codes at the time of the visit.
D) They make chart notes immediately available when a referral is needed.

Question 15

When filing alphabetically:

A) names are filed in a Z-to-A sequence from the first to the last letter
B) hyphenated surnames and hyphenated firm names are indexed as one unit
C) prefixes are not considered to be part of the surname
D) words such as and and for are disregarded and should be omitted

Question 16

The primary benefit of a(n)_____ filing system is that it distributes files evenly over given spaces.

A) chronologic
B) alphabetic
C) numeric
D) geographic

Question 17

The patient chart belongs to the:

A) patient
B) patient's insurance company
C) medical practice
D) person who prepared it

Question 18

When using the POMR method of record keeping,which of the following types of information appear on the same page?

A) medication lists and preventive care lists
B) the chief complaint and list chronic problems
C) education information provided to the patient,and the review of systems
D) the patient profile and list of chronic problems

Question 19

The primary disadvantage of the _____ filing system is that it requires a degree of familiarity of a certain area.

A) geographic
B) subject
C) alphabetical
D) chronologic

Question 20

What does the I in the HPIP method stand for?

A) investigate
B) impression
C) insurance
D) intestinal

Question 21

Match each example of information to the part of the medical record in which it would be found.
Breakdown of the drugs currently prescribed to a patient

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 22

Match each example of information to the part of the medical record in which it would be found.
Referral form from another physician

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 23

Match each example of information to the part of the medical record in which it would be found.
Patient's contact information (address,telephone number,etc. )

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 24

Match each term with its definition.
Designated individual who keeps track of which individuals have access to protected health information within a facility

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 25

Match each term with its definition.
This term once referred only to Roentgen films,but today also includes ultrasounds,angiograms,MRIs,and other types of images

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 26

Which filing system provides the most patient privacy?

A) alphabetical
B) subject
C) numerical
D) geographic

Question 27

Match each term with its definition.
These typically bear a disclaimer that states the report has or has not been reviewed for accuracy

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 28

Match each example of information to the part of the medical record in which it would be found.
Patient's insurance policy number

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 29

Match each example of information to the part of the medical record in which it would be found.
Patient's immunization record from the previous provider

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 30

Match each term with its definition.
Required before any information in a patient chart can be released

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 31

Match each term with its definition.
May offer the advantage of a treatment otherwise unavailable to a patient and additional care that might not have otherwise been provided

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 32

When you purge a file,you:

A) update it
B) clean it out
C) correct information in it
D) make a copy of it

Question 33

How often should the tickler file be checked?

A) daily
B) several times a day
C) weekly
D) several times a month

Question 34

Match each example of information to the part of the medical record in which it would be found.
Chronological record detailing a patient's progression during treatment

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 35

Match each example of information to the part of the medical record in which it would be found.
Copy of a patient's X-ray film

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 36

Match each example of information to the part of the medical record in which it would be found.
Preliminary report of a patient's test results

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 37

Match each term with its definition.
These indicate that a practice is utilizing the electronic record rather than just having a system in place in order to benefit from the federal incentive program

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 38

Match each example of information to the part of the medical record in which it would be found.
Request-of-information letter from a patient's insurance company

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 39

When filing alphabetically,if two names are identical,the address is used to make the filing decision in which order?

A) street,city,state
B) state,street,city
C) city,state,street
D) state,city,street

Question 40

Match each term with its definition.
Method of charting that encourages a clinician to provide greater detail of the information obtained during the interview and examination

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 41

​Identify equipment and supplies needed in order to store paper medical records.

A) ​shelves and file cabinets
B) ​OUTguides
C) ​barcodes and scanners
D) ​all of the above

Question 42

​Match the filing steps for medical records to the description.
​Step Four: put papers in alphabetical order

A)​inspecting
B)indexing
C)​coding
D)​sorting
E)​storing

Question 43

​Match the filing steps for medical records to the description.
​Step Five: locate the file drawer or shelf with appropriate caption;find the folder;…

A)​inspecting
B)indexing
C)​coding
D)​sorting
E)​storing

Question 44

Place the steps of filing in the correct order.
Inspect

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

Question 45

Place the steps of filing in the correct order.
Coding

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

Question 46

​Match the filing steps for medical records to the description.
​Step Two: requires you to make a decision about the name,subject,or other identifier under which you will file the material

A)​inspecting
B)indexing
C)​coding
D)​sorting
E)​storing

Question 47

Place the steps of filing in the correct order.
Storing

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

Question 48

​Match the filing steps for medical records to the description.
​Step One: divide reports into negative/normal and positive/abnormal for provider to read.

A)​inspecting
B)indexing
C)​coding
D)​sorting
E)​storing

Question 49

​Identify what would be part of maintaining a patient's medical record.

A) ​patient chart with record of visits
B) ​prescription refills
C) ​calls that pertain to the patient and calls a member of the health care team had with the patient
D) ​straighten and tidy the forms before filing

Question 50

Match each term with its definition.
Reprints are very often filed with this

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 51

Place the steps of filing in the correct order.
Indexing

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

Question 52

Match each term with its definition.
May be used to expedite both filing and finding of folders

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 53

​Which of the following is not one of the three components to satisfy meaningful use performance measures?

A) ​the use of a certified EHR technology to track patient demographics
B) ​the use of a certified EHR in a meaningful manner
C) ​the use of certified EHR technology to submit clinical quality and other measures
D) ​the use of certified EHR technology for electronic exchange of health information to improve quality of health care

Question 54

Place the steps of filing in the correct order.
Sort

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

Question 55

Match each term with its definition.
This should never be used when changing an incorrect entry in handwritten progress notes

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 56

​What act was signed into law as part of the American Recovery and Reinvestment Act that provides HHS with the authority to establish programs to improve health care quality through the promotion of health information technology?

A) ​HITECH
B) ​HIPAA
C) ​PPACA
D) ​ACA

Question 57

​Match the filing steps for medical records to the description.
​Step Three: marking the index identifier on the papers to be filed

A)​inspecting
B)indexing
C)​coding
D)​sorting
E)​storing

Question 58

​Which of the following would be a subjective statement?

A) ​You don't look well.
B) ​Your blood pressure is 124/92.
C) ​Your blood sugar is 325 mg/dL.
D) ​The patient's temperature is 37.9C/100.2F.

Question 59

Match each term with its definition.
Chronologic file used as a follow-up method for a particular date

A)privacy officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color-coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 60

​What equipment and supplies are needed to create medical records?

A) ​chart,folder,and tabs
B) ​patient records and privacy forms
C) ​computer and EHR program
D) ​all of the above

Question 61

When making a correction to the progress note in an electronic medical record,you should:

A) ​delete the entry and start over
B) ​use the edit feature
C) ​use the correction tab
D) ​all of the above

Question 62

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Implement drug-drug and drug-allergy interaction checks

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 63

​In the HPIP (history,physical exam,impression,plan)system of recording medical information,which is considered a subjective finding?

A) ​history
B) ​physical exam
C) ​impression
D) ​plan

Question 64

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 65

​Each filing system has pros and cons.Match the filing system to the "pros" description provided.
​Helpful in epidemiology or research or for maintaining business records including insurance

A)​alphabetic
B)​numeric
C)​geographic
D)​subject
E)​chronologic

Question 66

​Each filing system has pros and cons.Match the filing system to the "pros" description provided.
​Distributes files evenly over given spaces

A)​alphabetic
B)​numeric
C)​geographic
D)​subject
E)​chronologic

Question 67

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Record and chart changes in the following vital signs: height,weight,blood pressure,BMI,growth charts for children 2-20 years

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 68

​In the HPIP (history,physical exam,impression,plan)system of recording medical information,which is considered the assessment/diagnosis?

A) ​history
B) ​physical exam
C) ​impression
D) ​plan

Question 69

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 70

​In the HPIP (history,physical exam,impression,plan)system of recording medical information,which is considered an objective finding?

A) ​history
B) ​physical exam
C) ​impression
D) ​plan

Question 71

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Send patient reminders per patient preference for preventive/follow-up care

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 72

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Maintain active medication list

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 73

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Incorporate clinical lab-test results into EHR as structured data

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 74

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Implement drug formulary checks

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 75

​Each filing system has pros and cons.Match the filing system to the "pros" description provided.
​Easily understood and followed

A)​alphabetic
B)​numeric
C)​geographic
D)​subject
E)​chronologic

Question 76

​Each filing system has pros and cons.Match the filing system to the "pros" description provided.
​Useful for setting up callbacks of patients for follow-up visits at specified intervals

A)​alphabetic
B)​numeric
C)​geographic
D)​subject
E)​chronologic

Question 77

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Provide clinical summaries for patients for each office visit

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 78

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Provide patients with timely electronic access to their health information (including lab results,problem list,medication lists,and allergies)within four business days of the information being available to the EP

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 79

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives

Question 80

​Stage 1 of meaningful use focuses on data capture and sharing stage.Match the objectives to the description.Note: Answer may be used more than once.
​Record smoking status for patients 13 years or older

A)Stage 1-List of Eligible Professional Core Objectives
B)Stage 1-Eligible Professional Menu Set Objectives