Administrative Procedures: Chapter 10

EMR

The type of electronic record of health-record information about an individual that can be created, gathered, managed and consulted by only by authorized clinicians and staff in a single healthcare organization

HIPAA does not include requirements

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

To protect the patient's health and well-being

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

query-based exchange

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

Progressively

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

how many family members are healthy

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

HITECH Act

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

Draw two clear lines through the error.

Which statement is not accurate about correcting charting errors?

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

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

voice recognition

_____ software can be used for transcription and authentication

drawing a line through the entry and riding the correct information

a correction to a medical record can be made by:

indirect filing

A filing system in which an alphabetic cross-reference must be consulted to locate specific files is called a(n) _____ system

a new entry or addendum must be added close to the original entry with the correct information and then initialed

how are corrections made to the electronic health record?

physician or provider

The physical health record belongs to

closed

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

both statements are true

for a record to be admissible as evidence in court, the person dictating or riding 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 type or thr entry

Tickler file

most frequently used follow-up method is a:

true

true or false, the software of an electronic health record system can be designed to be compatible with a medical specialty office, such as Pediatrics or oncology

false

true or false: PHI stands for Private health information

false

true or false: Physicians performing consultations still must request paper records on the patient, even if both the referring physician and Consulting physician are using an electronic health record system

true

true or false: a provisional diagnosis is not a final diagnosis and is usually made before test results are received

false

true or false: a standard, Nationwide rule must be followed in establishing a records retention schedule

true

true or false: by legal definition, if it is not documented, then it did not happen

false

true or false: charge capture relates to charges for missed appointments

false

true or false: color coding is only used for patients records and not for business records

true

true or false: health records offer protection to the provider during legal proceedings if they are accurate and complete

true

true or false: information contained in an electronic health-record usually can be accessed from several different physical places

true

true or false: less storage space is needed for electronic health-record systems

all are correct

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

charge capture

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

numeric filing

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

filing activity is greatest when the system is initiated

which of the following is not an advantage of the numeric filing system?

the patient

who ultimately decides whether a medical record can be released?

Freeman, Jill M.D.

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?

HIPAA does not recommend a number of years

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

written release from the patient

The medical record should be released only with a

erase or use a correction fluid

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

education

the E entry in the soaper charting method means

all are correct

the advantages of using the color-coding filing system are the following:- I miss filed record is easily spotted from a distance - the use of color visually restricts the area of search for a specific record - you can use either the alphabetic or numeric color coding system - all are correct

all are correct

the medical assistant should consider which of the following When selecting filing equipment?- fire protection - cost of space and Equipment - confidentiality requirements - or correct

purging

the process of moving an active file to inactive status is called:

response

the r entry in the soaper charting method means

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

Medical facilities should keep records on minors for how long?

EHR

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 an...

medical attention that continues smoothly from one provider to another so that the patient receives the most benefit

continuity of care means:

true

true or false: numeric filing provides extra confidentiality to medical records

true

true or false: reverse chronological order is where the most recent item is on top and older items are filed farther back

false

true or false: subjective information is that which the provider observes during a physical examination of the patient

true

true or false: the EHR system can allow patients to set their own appointments using the internet

false

true or false: the computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages

true

true or false: the electronic health record allows access to patient information in an emergency

false

true or false: the electronic medical record relates to more than one Healthcare organization

true

true or false: the hitech ACT stands for health information technology for economic and clinical Health Act

false

true or false: the patient owns the medical record

true

true or false: the patient's health record should never leave the office

false

true or false: the system is not capable of telling whether a certain procedure matches a specific diagnosis code

true

true or false: the three basic filing methods are alphabetic, numeric, and alphanumeric

false

true or false: usually, more staff members are needed when an office uses an electronic health record system

false

true or false: very little statistical information can be gleaned from an HR System

true

true or false: when documents are added to a patient's paper record, the most recent information should be placed on top