MOA115/CH 11-12 Review

Medical facilities should keep records on minors for how long?

Until the minor reaches the age of majority, plus 3 years

If a chronological numeric filing system is used, which of the following medical records comes last in the files?

7354

If Mary Jane Lincoln marries John L. Wallace, which of the following names might Mary Jane choose to use as her married name?

All of the above

Which of the following is NOT an advantage of color-coded filing systems?

All of the above are advantages

Most diseases or conditions arranged in the tabular section of the ICD-10 manual by?

By classification of disease or condition

Which term defines a malignant site as the absence of invasion of surrounding tissues?

Ca in situ

Files for patients who have died, moved, or otherwise terminated their relationship with the physician are called ______ files.

Closed

What does continuity of care mean?

Continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care.

In the ICD-10, which term indicated that a condition is not coded here, and the patient cannot have this condition in addition to the condition listed above it?

Excludes I

One reason for keeping accurate medical records because the patient's family may want to examine the records and correct error.

False

Progress notes, Family History, Diagnosis, and Physical exam and findings are all objective information.

False

If a diagnosis is listed by the physician S "skull fracture base condyle type 1 left side" which word should be referenced in the alphabetic index of the ICD-10 manual?

Fracture

Which HER system backup is probably the least trouble and requires the least amount of hardware?

Fullserver backup

A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files is called a (n) _______ system?

Indirect filing system

What are three advantages of a numeric filing system?

It allows unlimited expansion without periodic shifting of folders, and shelves usually are filed evenly. It provides additional confidentiality to the record. It saves time in retrieving and filing records quickly.

Using the alphabetical system of filing,what would "The Jackson Medical Supply Company" be filed under?

J

Which of the following would be filed first?

Jones, Janice

What is the format of the first three characters of an ICD-10 code?

One letter followed by two digits

The period from the last month of pregnancy to 5 months after giving birth is called?

Peripartum

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

Progressively

The medical record should be released only with a

Release of Information formed signed by the patient

Which ICD-10 section includes guidelines for reporting additional diagnosis in non-outpatient settings?

Section III

Which of the following names would be filed first?

St. Crusis, Josephine

How would you properly index the name "Jessica M. Stillman-Douglas" for filing?

Stillmandouglas, Jessica M.

Information that is gained by questioning the patient or that is taken from a form is called _______ information.

Subject

_____ are intended one space to the right under an essential modifier.

Subterms

How would you properly index the name "Patricia Swanson, M.D." for filing if you had another patient with the same name but without the title?

Swanson, Patricia M.D.

Who is the legal owner of the information stored in a patient's medical record?

The patient

The code HIV indicates which of the following?

The virus is present

Rotary circular files, Lateral Files, and Automated Files are common types of filing equipment found in a medical office?

True

Which volume (s) of ICD-10-CM is/used for diagnostic coding?

Volume 1 and 2

Which of the following would be filed first?

William De La Mart

What are the acceptable methods of correction to a handwritten entry?

a line should be drawn through the error. the correction inserted above or immediately after, and the person making the correction should write his or her initials or signature and the data below the correction

Which of the following is an advantage of the HER system?

ability of the physician to see more patients in a day.

What is the purpose of external cause codes in the ICD-10?

extended to provide data for research on the injury and for evaluation on prevention on strategy.

A code from category Z37 should be included on

mothers (maternal) health record

In the ICD-10 code M01.X3, what is the function of the "X"?

placeholder

Voice recognition software can be used to dictate which types of reports?

progress motes, letters, emails and virtually any document in the healthcare facility that needs to be created.

Burns are coded by

site and degree and by the extent of body surface involvement

What is the most frequently used follow-up method?

tickler file

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

to protect the patient's health and well being

What is the second most common medical document from which diagnostic statements can be extracted?

treatment notes