HPR 1008 Chapter 7

Medical records should never include what things? 1. Inappropriate judgments 2. Consent forms 3. Attempts at humor 4. Objective data

1 & 3

Which of the following are steps to take when correcting an error on a medical record? 1. Draw a line through the incorrect information so that it is still legible 2. Cross out the error multiple times so that it is illegible 3. Do it in privacy 4. Enter the date and time, and initial the correction

1 & 4

What are some of the ways in which social media is used in healthcare today? 1. Training. 2. Communicate with consumers. 3. Times of crisis. 4. To speak about specific people.

1, 2, & 3

What are some things that a patient portal may allow you to see? 1. Medications 2. Immunizations. 3. Discharge summaries. 4. Fees.

1, 2, & 3

What are the benefits of telemedicine for patients? 1. It reduces stress for patients. 2. It gives improved access. 3. It reduces travel time for patients. 4. It increases frequency of visits.

1, 2, & 3

Which of the following are purposes for medical records? 1. They serve as legal documents in lawsuit. 2. They provide a foundation for managing a patient's health care. 3. They are required by licensing authorities. 4. They contain only positive results of tests.

1, 2, & 3

Which of these are necessary attributes of entries to patients' health records? 1. Clear 2. Concise 3. Correct 4. Certified

1, 2, & 3

Depending on the record type, which of these are common ways to destroy records? 1. Burning 2. Demagnetizing 3. Erasing 4. Shredding

1, 2, & 4

What are some reasons that a physician may receive a subpoena for medical records? 1. An accident involving the patient 2. Workers' compensation claims 3. Adoption proceedings 4. Nonmedical-liability reasons

1, 2, & 4

What are some reasons that a physician may receive a subpoena for medical records? 1. Worker's Compensation claims. 2. Non-medical liability reasons. 3. Adoption proceedings. 4. An accident involving the patient.

1, 2, & 4

What does health IT include? 1. Electronic prescribing. 2. EHR's. 3. Informed consent. 4. PHR's.

1, 2, & 4

When using the Internet to obtain health and medical information, what should the user ask? 1. Does that sound like a miracle cure? 2. Who is the site sponsor? 3. Is this site promising me results? 4. Are several reliable websites offering similar information?

1, 2, & 4

In all modifications to a patient record, what must be immediately visible to a user? 1. When the change was signed 2. Length of time between original and new documentation 3. Who made the change 4. A change has been made

1, 3, & 4

What was the focus of stage one of the HITECH act of 2009? 1. Adoption by providers of certified EHR's 2. Decreased safety and efficiency. 3. E- prescribing. 4. Incentives to those providers who adopted certified systems were set.

1, 3, & 4

Place the guidelines for complying with a subpoena for medical records in the correct order

1. Check the subpoena to be sure the name and phone number of the issuing attorney and the court docket number of the care are listed. 2. Verify that the patient named was a patient of the physician named. 3. Check all subpoenaed records to be sure they are complete, but never alter them in any way. 4. Offer sworn testimony regarding the record, if so instructed by the court.

What guidelines should the person in charge of medical records follow when a physician's records are subpoenaed in a malpractice suit? 1. Do not tell the physician that a subpoena was received. 2. Document the number of pages in the record, an itemize the contents. 3. Verify that the patient named was a patient of the physician named. 4. Ignore the subpoena until instructed by the physicians attorney.

2 & 3

If a subpoena is received, the person in charge of medical records, should 1. Send the original chart immediately. 2. Offer sworn testimony, if needed. 3. Tell no one about it. 4. Verify the trial date and time as listed.

2 & 4

What are the characteristics of an electronic health record (EHR)? 1. The information is all in one paper based document 2. It has all information in one electronic platform 3. It cannot be shared with other health care providers 4. It is built to share information with other health care providers

2 & 4

Common reasons why a patient's medical information is released include which of the following? 1. Divorce proceedings 2. Insurance claims 3. Transfers to another physician 4. For use in a court of law

2, 3, & 4

When considering reliability of health information on social media, site sponsorship by which of the following may present reliable information? 1. Sites with .org as a suffix. 2. Government agencies. 3. Sites sponsored by or linked with major medical centers. 4. Medical professionals.

2, 3, & 4

Which of the following is considering social media? 1. Nanogroups. 2. Microblogs. 3. Gaming. 4. Photo sharing.

2, 3, & 4

Which of the following should be included in a medical record? 1. Patient's political affiliation 2. Emergency contact information 3. Description of the patient's symptoms 4. Patient's health history

2, 3, & 4

What percentage of adults 18 to 24 do not see a medical professional annually?

40%

What percentage of patients were required to download and or transmit health information via an approved patient portal as part of successful attestation for stage two?

5%

In a survey done in April 2018, the American Osteopathic Association found that __________ percent of millennials either are or would like to be friends with their healthcare provider on a social media platform.

54%

A(n) __________ is used to clarify or correct information in the electronic health record.

Amendment

What is new documentation used to add information to the original entry called?

An addendum

When did the centers for Medicare and Medicaid services (CMS) announced that the term EHR incentive programs (meaningful use) would be renamed to promoting interoperability (PI) programs?

April 2018

Destruction of PHI by a health care facility or provider must be carried out according to what guidelines?

Federal and state laws

What percentage of Americans have taken an action related to their health as a result of information they have read on social media?

Nearly one-third (32 percent)

What information should be released when requested?

Only the information requested should be released

In the past, a medical record was created, maintained, and stored in what format?

Paper

A challenge of telemedicine that is being met is _____________ for services.

Payment

What do physicians do with a medical record when they receive a subpoena?

Photocopy the records and send them to the appropriate attorney

Which of the following is included in a medical record to provide continuity of care?

Physician's recommendations

Why are medical records retained?

Protection from litigation

A policy for using an addendum in an electronic health record includes which of the following?

Reason for the addenda, actual information, and time period

An example of a private social media network available to license physicians to share information is called

Sermos

Records involved in any open investigation, audit, or litigation must not be destroyed until ___________.

The investigation has been closed

What is the focus of Stage 3 of meaningful use?

To continue to improve patient access.

What are the ranges of the statute of limitations for record retention for adults?

Two to seven years

Check a subpoena for

Verification that the issuing attorney is the same as the original if the subpoena is a photocopy and the trial date and time.

When does a patient's medical record end?

When they die

When is the only time that the patient's written consent to release their medical records is waived?

When used in a court of law

What is required for the release of medical records to a third party?

Written permission

Studies suggest that telemedicine can reduce healthcare costs through better management of

Chronic diseases or illness

A(n) __________ is a change in the information that is meant to clarify inaccuracies found after the document is complete.

Correction

AHIMA recommends that facilities destroying health records permanently maintain ___________

Documentation or proof

What is built with patient's total health information in one record that can move electronically with the patient for treatment and care?

Electronic health record

When a physician is sued for medical malpractice, responsibility to comply with a subpoena to produce specified documents in court, may fall to which staff?

Employee in charge of medical records

The electronic medical record (EMR) is the electronic form of a patient's medical history for what type of data?

From just one practice

Under what law does a patient have a right to see and get copies of his/her health information and share with a third-party?

HIPAA

What is the electronic systems health care professionals- and increasingly, patients- use to store, share, and analyze, health information called?

Health Information Technology

What does stage 2 of HIT focus on?

Health information exchange and Interoperability

What is the electronic systems healthcare professionals and increasingly patient used to store share and analyze health information called?

Health information technology

Which of the following is true regarding a medical record?

It is a legal document

What is certified electronic health record technology to improve quality, safety, efficiency and decrease disparities in health called?

Meaningful use

What is certified electronic health records technology to improve quality, safety, efficiency and decrease disparities in health called?

Meaningful use

Medical records were completed for the treatment provided by which of the following entities?

Medical facility, physician/practice, hospital

A collection of data recorded when a patient seeks medical treatment is called a

Medical record

What do EMRs allow health providers in facilities to do?

Monitor and improve overall patient care, track data over time, and check patients' progress within certain parameters