chapter 2,4,5 TEST
medical facilities should keep records on minors for how long?
until the minor reaches the age of majority, plus 3 years
the type of electronic record of health-related information about a patient that conforms to nationally recognize interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization is a(n)
EHR
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)
EMR
how would you properly index the name "Amanda M. Stiles_Duncan" for Filing?
Stilesduncan, Amanda M.
Advantages of the EHR system include
ability of the physician to see more patients a day
Many healthcare facilities now use voice recognition software for transcription. The system can be used to dictate which types of reports?
all of the above
The medical assistant should consider which of the following when selecting filing equipment ?
all of the above
disadvantages of the EHR system include
all of the above
the advantages of using the color-coding filing system are the following :
all of the above
which of the following are common types of filling equipment found in a medical office?
all of the above
which of the following is not an advantage of color-coded filing systems?
all of the above
The "E" entry in the SOAPER charting method means?
evaluation
which of the following is not objective information?
family history
which of the following is NOT an advantage of a numeric filing system?
filing activity is greatest when the system is initiated
which of the following is NOT needed when describing a patients chief complaint?
how many family members are healthy
a filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific file is called ...... system
indirect filing
Continuity of care mean?
medical attention that continues smoothly from one provider to another so that the patient receives the most benefit
which statement is not true regarding the reasons for keeping accurate medical records?
the patients family may want to examine the records and correct errors
Who is the legal owner of the information in a patient's medical record?
the physician or agency where services were provided
The most frequently used follow-up method is a
tickler file
what is the most important reason for telling the physician when a charting error is discovered later?
to protect the patients health and well-being
how would you properly index the name ''Jill Freeman, M.D." for filling if you had another patient with the same name but without the title?
Freeman, Jill M.D.
HIPAA recommends that physicians keep the records on patients for at least
HIPAA does not recommend a number of years
a set of physical properties, the values of which determine characteristics or behavior, is called
parameters
the physical medical record belongs to the
physician or provider
A strong, highly glazed composition paper or heavy and stock is called
pressboard
which of the following is not a method of organizing a medical record?
progressively
the process of moving an active file to inactive status is called
purging
Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files.
closed
which statement is NOT accurate about correcting charting errors?
draw two clear lines through the error
a correction to a medical record can be made by?
drawing a line through the entry and writing the correct information
The "R" entry in the SOAPER charting method means
response
information that is gained by questioning the patient or that is taken from a form is called .......... information
subjective
The preferred filing method for a physicians office is
the one most preffereed by the staff
Who ultimately decides whether a medical record can be released?
the patient
the newest component used today to complete transcription and authenticate records is............ software?
voice recognition
The medical record should be released only with a
written release from the patient