322- Chapter 10- Health Records

HITECH Act stands for Health Information Technology for Economic and Clinical Health Act.

True- HITECH Act stands for Health Information Technology for Economic and Clinical Health Act.

By legal definition, if it is not documented, then it did not happen.

True- If an action is not documented in the health record, then it is considered not to have happened.

Health records offer protection to the provider during legal proceedings if they are accurate and complete.

True- If health records are accurate and complete, they will protect the actions of the provider during medical professional liability proceedings.

Numeric filing provides extra confidentiality to medical records.

True- Numeric medical records are considered the most confidential.

PHI stands for "private health information."

True- PHI stands for "protected health information."

The patient's health record should never leave the office.

True- Patients' medical records should never leave the medical office.

A provisional diagnosis is not a final diagnosis and usually is made before test results are received.

True- Provisional diagnoses usually are made before the final diagnosis and before all test results have been obtained.

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

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

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

True- The most recent information should be on top in patients' medical records.

The three basic filing methods are alphabetic, numeric, and alphanumeric.

True- The three basic filing methods are alphabetic, numeric, and alphanumeric.

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

A new entry or addendum must be added close to the original entry with the correct information and then initialed.- When electronic health records are corrected, the record must be entered (through the log-on process) and then an addendum can be made to correct the information in the record. The addendum is initialed by the person who makes the correction.

The medical assistant should consider which of the following when selecting filing equipment? -Fire protection -Cost of space and equipment -Confidentiality requirements -All are correct

All are correct- Many considerations should be evaluated when considering filing equipment.

Which of the following are common types of filing equipment found in a medical office? -Rotary circular files -Lateral files -Automated files -All are correct

All are correct- Rotary circular files, lateral files, and automated files are all types of filing equipment that might be found in a medical office.

The source-oriented medical record (SOMR) categorizes the content by its source, such as provider, laboratory, radiology, hospital, and consultation.The problem-oriented medical record (POMR) categorizes each of the patient's problems and elaborates on the findings and treatment plans for all concerns -Both statements are true -Both statments are false -First statement is true; second statement is false. -First statement is false; second statement is true.

Both statements are true.- The source-oriented medical record (SOMR) categorizes the content by its source, such as provider, laboratory, radiology, hospital, and consultation. Within each source category the content is arranged in reverse chronologic order so that the most recent content is viewed first.The problem-oriented medical record (POMR) categorizes each of the patient's problems and elaborates on the findings and treatment plans for all concerns. Detailed progress notes are kept for each individual problem. This method addresses each of the patient's concerns separately, whereas a source-oriented record may address all problems and concerns at one time, usually covering one to three patient concerns per office visit. The POMR helps ensure that individual problems are all addressed.

Which statement is not accurate about correcting charting errors? -Insert the correction above or immediately after the error. -Draw two clear lines through the error. -In the margin, initial and date the error correction. -Do not hide charting errors.

Draw two clear lines through the error.- Only one line should be drawn through errors when corrections are made.

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): -EMH. -EHR. -EMR. -PHI.

EHR- The EHR can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization.

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): -PHR -EHR -EMR -PHI

EMR- The EMR is compiled by the staff at a single organization involved in the patient's care.

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

False- An incredible amount and variety of statistics can be calculated from an EHR system.

The computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages.

False- Both computer-based and paper-based records have advantages and disadvantages.

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

False- No standard has been established nationally for the retention of medical records.

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

False- Objective information is observed during the physical examination.

Charge capture relates to charges for missed appointments.

False- The charge capture functions can store lists of ICD and CPT codes, as well as the charges associated with procedures and supplies.

The patient owns the medical record.

False- The maker of the medical record is its owner; in the physician's office, the physician is the maker/owner of patient medical records.

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? -Dr. Jill Freeman -Freeman, Dr. Jill -Freeman, Jill -Freeman, Jill M.D.

Freeman, Jill M.D.- The title should be used in filing systems to distinguish a person from one who does not have a title.

HIPAA recommends that physicians keep the records on patients for at least: -1 year. -2 years. -3 years. -HIPAA does not recommend a number of years.

HIPAA doe not recommend a number of years.- HIPAA does not offer a recommendation on record retention; it prompts facilities to follow their individual state laws.

Which section of the law, commonly known as the Economic Stimulus Package, pertains to healthcare? -ARRA -HITECH Act -HIPAA -None are correct

HITECH Act- The sections of the ARRA that pertain to healthcare are collectively known as the Health Information Technology for Economic and Clinical Health Act, or HITECH Act. The American Recovery and Reinvestment Act of 2009 (ARRA), commonly known as the Economic Stimulus Package, was passed to promote economic recovery.

Which of the following is not needed when describing a patient's chief complaint? -Remedies the patient has tried to relieve symptoms -The duration of pain -The time when symptoms were first noticed -How many family members are healthy

How many family members are healthy- The chief complaint is the main problem the patient is currently experiencing. The medical assistant should note the remedies the patient has tried, the duration of any pain, and the time that symptoms were first noticed. The number of healthy family members is not necessary information about the chief complaint but would be part of the family history.

Which of the following is not a method of organizing a medical record? -Source oriented -Problem oriented -Progressively -Chronologically

Progressively- Medical records can be organized chronologically or as source-oriented or problem-oriented records. There is no such thing as a progressive type of record organization.

Which statement is not true regarding the reasons for keeping accurate medical records? -The medical record provides critical information for other caregivers. -Effects of various treatments can be tracked and statistics gleaned from them. -The patient's family may want to examine the records and correct errors. -Accurate records are vital for financial reimbursements.

The patient's family may want to examine the records and correct errors.- Accurate records are not kept to appease the patient's family; they are kept, ultimately, to provide appropriate patient care.

Who ultimately decides whether a medical record can be released? -The physician -The office manager -The medical assistant -The patient

The patient- The patient ultimately decides whether his or her medical record can be released.

What is the most important reason for telling the physician when a charting error is discovered later? -To protect the patient's health and well-being -To protect the medical assistant's job -To make sure the medical assistant is not accused of making the error -To keep the patient from discovering the error

To protect the patient's health and well-being.- The most important reason to report errors in the medical record is to make sure the patient's health and well-being are not jeopardized.

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

closed- The files of patients who are no longer active, such as those who have moved away, died, or otherwise terminated their relationship with the physician, are called closed files.

The "E" entry in the SOAPER charting method means: -entry. -evaluation. -education. -exclude. -evaluation or education

evaluation or education- The "E" entry signifies either patient education or the physician's evaluation that occurred during the encounter with the patient.

A filing system in which an alphabetic cross-reference must be consulted to locate specific files is called a(n) _____________ system. -shelf filing -indirect filing -direct filing -shingling

indirect filing- An indirect filing system uses an alphabetic cross-reference to locate specific files.

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

medical attention that continues smoothly from one provider to another so that the patient receives the most benefit.- Continuity of care is medical attention that moves smoothly from one provider to another so that the patient receives the most benefit.

The process of moving an active file to inactive status is called: -purging. -indexing. -coding. -conditioning.

purging- Purging is the process of moving active files into inactive status.

The most frequently used follow-up method is a: -tickler file. -transitory file. -practice management file. -None are correct

tickler file.- The most frequently used follow-up method is a tickler file, the so-called because it tickles the memory that something needs to be done or followed upon on a particular date.

The medical record should be released only with a: -verbal order from the physician. -written order from the physician. -written release from the patient. -verbal order from the office manager.

written release from the patient.- Records should be released only with a written authorization from the patient.