Chapter 13 - Medical Records Management

What is the purpose of HIPAA? Select all that apply. a. make transferring medical records easier b. establish standards for electronic transmission of health records c. ensure the security of electronic health information d. maintain the privacy of health information

All but a

Uses the letters of the patient's last name

Alphabetic filing

In the acronyms so the letters stand for subjective complaint, objective findings,... Of the problem, and plan of treatment

Assessment

Method of designation used on file guides

Caption

If there are a number of reports/documents to be filed, they should be sorted into unity according to the... On the charts

Captions

.... Files are those that are no longer required

Closed

Mr. Henderson died six months ago at the age of 99. Which category with his chart be filed in

Closed files

Serial or... Filing is a method in which numbers are considered in ascending order using the entire set of figures

Consecutive

Notation in a file to direct the reader to a specific record that may be filed under more than one name/subject where the surname is not easily recognizable. I.e. married name/maiden name or foreign names.

Cross reference

The correct way to make a correction in a paper-based medical record is to

Draw a line neatly through the incorrect entry so it remains legible, write the correct information, then date and initial the change.

The physician must initial only those laboratory reports with abnormal values before they were filed in a patient's medical record.

False

What is the patient's father and mother living in the wild, age at death, and because of that, is information found in

Family history

Which indexing unit is the patient's surname?

First

Selecting the name, subject, or number under which to file a record and determining the order in which the units should be considered

Indexing

When the doctor uses palpation to examine the patient, she

It's touching and feeling various parts and organs of the body

First indexing unit of the filing segment

Key unit

A centers for Medicare and Medicaid program that awards and centers are using certified electronic health records (EHR) to improve patient care.

Meaningful use

Requires a tickler file to locate the identifier

Numeric filing

Card, folder, or slip of paper inserted temporarily in the files to replace a record that has been retrieved from the files.

Out guide or sheet

Which statement is accurate regarding filing correspondence?

Paper clip should be removed, and the item should be stabled together

Includes a patient's alcohol and tobacco usage

Past, family, and social history

Includes a patient's demographics information

Patient information form

Includes a patient operations, accidents, or injuries

Patient medical history

Tabular form of the patient conditions which may be cross-referenced with medication

Problem - oriented medical record POMR

Method of maintaining order in files by separating active from in active and closed files

Purging

Often used by a laboratory reports

Shingling

Groups info by type, such as laboratories, and exams

Source - oriented medical record SOMR

________ filing places charts in exact chronological order according to a signed number

Straight numeric

Data file the most recently charted materials on top

Strict chronological arrangement

Uses business information

Subject filing

What is the correct description of SOAP charting?

Subjective, objective, assessment, plan

In... Filing, a six digit number is most often used with a hyphen dividing three parts to of two to digits for example 85-32-07.

Terminal digit

Uses numbers that indicate shelves or drawers where the file is housed

Terminal digit filing

System to remind of action to be taken on a certain date

Tickler file

Explaining HIPAA to a patient addresses one of the rights incorporated in the Patient's Bill of Rights.

True

Which of the following are components necessary for proper documentation in a patient's medical chart? Select all that apply. a. timely entries b. factual information c. appropriate signatures d. financial information

a,b,c

Identify which items are subjective. Select all that apply. a. ringing in the ears b. headache c. Weight 152 lbs d. BP 152/88 e. dizziness f. distended abdomen

a,b,d

Barbara Jane Howard, married to George Howard, is a new patient. What statement is accurate regarding the indexing of her name? a. Howard is the primary indexing unit. b. Jane is the secondary indexing unit. c. Mrs. George is the third indexing unit. d. Mrs. George is the secondary indexing unit.

a. Howard is the primary indexing unit.

Which medical record places vital identification data, immunizations, allergies, medications, and problems in a prominent location? a. POMR b. SOAP c. SOMR d. SOAPER

a. POMR

What is the name of the system used as a reminder of action to be taken on a certain date? a. Tickler file or reminder note b. Accession log c. Purging system d. Release mark e. Outguide

a. Tickler file or reminder note

When identical names are being indexed, which indexing system is preferred in a medical system? a. The birth date or Social Security number b. The address c. A preassigned clinic number d. The telephone number

a. birth date or Social Security Number

All of the following are types of files cabinets used in medical clinics where manual files are stored EXCEPT: a. horizontal b. moveable. c. vertical. d. lateral.

a. horizontal

Of the four systems of filing, what is the best for every ambulatory care setting? a. One customized to the needs of the clinic b. The numeric system c. The alphabetic system d. The color-coding system

a. one customized to the needs of the clinic

The ... record is a journal or computer listing or numbers are pre-assigned to patients

accession

Select all the functions which may be performed using a state of the art EHR system. Select all that apply. Patient Financial Management and Medical Records Management may interface A prescription may be sent directly to the pharmacy The medical record may be viewed from multiple sites Patient demographics are automatically populated on patient statements

all of these choices

Which rules apply when filing patient charts? Select all that apply. a. When titles are used, they are considered as one indexing unit with the unit that follows. b. Names that include a single letter are placed before full names beginning with the same letter. c. Foreign language prefixes are indexed as separate units. d. Names of individuals are assigned indexing units: Last name, first name, middle, and succeeding names.

b and d

Which is the correct definition of HIPAA? a. Health Information Privacy Accountability Act b. Health Insurance Portability and Accountability Act c. Health Information Private Association Act d. Health Insurance Preauthorization and Accountability Act

b. Health Insurance Portability and Accountability Act

When is the patient's medical chart prepared? a. The patient prepares his or her chart online prior to the first appointment using the clinic's Web site. b. The patient's chart is prepared on or before the day of the patient's first visit. c. The patient's chart is prepared while the patient waits in the reception area. d. The patient's chart is prepared after the patient's first visit.

b. The patient's chart is prepared on or before the day of the patient's first visit.

What is the process for making corrections to the medical record? a. They are made only by the provider. b. They are made by placing a single line through the error and replacing it with the correction. c. They are made by erasing the error and replacing it with the correction. d. They are never made to charts because of the legal nature of the information.

b. They are made by placing a single line through the error and replacing it with the correction.

All of the following are considered possible advantages of the electronic medical record EXCEPT: a. multiple users are possible. b. it is currently established and understood. c. patterns and data are more easily accessed. d. errors are less likely.

b. it is currently established and understood.

What is the name of the tool used to ensure that records are tracked when borrowed in order to maintain an accurate filing system? a. Cross-reference file b. Out guide c. Alphabetic card file d. Release mark

b. out guide

The __________ groups information in categories such as laboratories, examinations, provider notes, and consulting providers. a. SOAP medical record b. source-oriented medical record (SOMR) c. problem-oriented medical record d. chronological medical record

b. source-oriented medical record (SOMR)

__________include documentation such as the medical history, the physical examination, and the follow-up notes. a. Laboratory reports b. Correspondence c. Clinical notes d. Miscellaneous reports

c. Clinical notes

All of the following statements are true with regard to correcting the electronic medical record EXCEPT: a. Each EMR has its own method of handling corrections and tracking them. b. Generally, a correction is made using the "Edit" function. c. Generally, a correction is made using the "Delete" function. d. Only certain staff members are able to alter or correct EMRs.

c. Generally, a correction is made using the "edit" function.

What are the preferred steps for filing medical documentation? a. Code, index, sort, inspect, file b. Sort, inspect, index, code, file c. Inspect, index, code, sort, file d. Inspect, index, code, purge e. Inspect, code, index, sort, file

c. Inspect, index, code, sort, file

What answer describes the correct indexing for units 1, 2, 3, 4 in the name John Porter O'Keefe II? a. II O'Keefe John Porter b. John Porter O'Keefe II c. O'Keefe John Porter II d. The "II" would be disregarded e. John Porter O'Keefe

c. O'Keefe John Porter II

What is the name of the process for maintaining order in files by separating active from inactive files? a. Indexing b. Coding c. Purging d. Alphabetizing

c. Purging

Guidelines for correcting the medical record include all of the following EXCEPT: a. writing "Corr." or "Correction" above the area corrected. b. indicating the current date. c. drawing a single line through the error in black ink. d. indicating your initials.

c. drawing a single line through the error in black ink.

What is the name of the process for maintaining order in files by separating active from inactive files? a. Indexing b. Coding c. Purging d. Alphabetizing

c. purging

State statutes have ruled that medical records are the property of _________. The information within the medical record, however, belongs to __________. a. the patient; the state b. the physician; the state c. those who create them; the patient d. the state; the physician

c. those who create them; the patient

All of these statements are accurate regarding an accession record EXCEPT: a. A computerized system would have an accession record in its memory bank. b. Each new entry for which a chart will be created must be assigned a letter. c. An accession record is a journal or computer listing used to preassign numbers to patient records. d. An accession record filing system requires a cross-reference file.

d. An accession record filing system requires a cross-reference file.

Which statement is accurate regarding the Tab-Alpha coding system? a. The color-coded labels contain all of the indexing units. b. It can only be used only in a numeric filing system. c. No additional labels can be attached to the chart. d. Colored labels are applied for the first two letters of the key indexing unit.

d. Colored labels are applied for the first two letters of the key indexing unit.

Which of the following types of medical records groups information according to its source? a. POMR b. SOAP c. SOAPER d. SOMR

d. SOMR

All of the following statements regarding ownership of medical records are true EXCEPT: a. The information within the medical record belongs to the patient. b. The patient can request that certain information not be included in their files. c. Medical records are the property of those who create them. d. The information within the medical record belongs to the healthcare provider.

d. The information within the medical record belongs to the healthcare provider.

Which of the following statements about EMRs is false? a. They eliminate coding and filing of medical charts. b. They create reminders for follow-up as necessary. c. They are initially more expensive than paper medical records. d. They should be available to most Americans by 2020. e. Solo practitioners are least likely to use EMRs.

d. They should be available to most Americans by 2020.

Who owns the medical record? a. The patients for whom the record is about b. Insurance carriers who help to pay medical costs c. The providers who create the record d. The insurance carrier e. Both a and c

e. both a. & c.

inactive files may be purged.

false

A ... Is a device or sheet that helps in tracking charts when one chart is removed

out guide

a ... mark indicates that the material is ready to be filed.

release

The first indexing unit of the filing segment is known as

the key unit

Each part of a name (business or person) , words, or numbers that will be indexed and coded for filing.

unit