Mod 1-Week 3 -Chapter 26. The Medical Record, Documentation, and Filing

progress notes

record of the continuing progress and treatment of a patient

Use of a geographic filing system: a. distributes files evenly over given spaces. b. is useful in community health environments. c. is helpful in epidemiology or research or for maintaining business records including insurance. d. is useful for setting up callbacks of patients for follow-up visits at specified intervals.

b. is useful in community health environments.

ethnicity

demographic term that indicates with what societal group a patient identifies himself/herself

Stage 3 (Meaningful Use) Improved Outcome

Clinical decision support for national high-priority conditions

One of the most frequently used data collection methods for patient visits is the SOAP note. What does the acronym SOAP stand for? a. submission, objective, assessment, plan b. subjective, objective, assessment, plan c. subjective, observant, ascertain, provide d. submission, observant, ascertain, provide

b. subjective, objective, assessment, plan

The patient's chart legally belongs to: a. the patient. b. the provider or practice. c. the insurance company paying for services. d. All of the above.

b. the provider or practice.

The patient's temperature is 37.9°C/100.2°F

objective

I have a headache

subjective

purge

to clean out files of those patients who are no longer being seen by the provider

_______ filing refers to filing according to date. -Alphabetic -Subject -Chronologic -Geographic

-Chronologic

The focus of the HIPAA ______ applies to paper records, but is primarily concerned with electronic information and methods to protect it from invasion, accidental disclosure, or loss. -Privacy Rule -Security Rule -HPIP mandate -HITECH Act

-Security Rule

HIPAA regulations and recommendations require a designated _______ must keep track of who has access to protected health information within a facility. -security officer -electronic security officer -privacy officer -outside auditor

-privacy officer

The purpose of meaningful use is not only to institute the adoption of EHRs, but to ascertain that practices use their EHR software ______. -to its fullest -everyday -for administrative documentation only -for clinical documentation only

-to its fullest

Keep in mind that the first indexing unit of a coded unit should be _______ to assure proper filing. -highlighted -underlined -bolded -color-coded

-underlined

HIPAA requires all medical records, signed consent forms, authorization forms, and any other HIPAA-related documents to be retained for ______ years. Records of deceased patients must be maintained for ______ years. 1. -two -six -five 2. -two -six -five

1. -six 2. -two

The _______ information is supplied by the patient and includes routine information about the patient, past personal and medical history, family history, and chief complaint. The provider and various members of the health care team provide _______ information (e.g., vital signs, exam findings, diagnostic tests, and so on). 1. -subjective -assessment -objective 2. -subjective -assessment -objective

1. -subjective 2. -objective

In the event of an audit, the Centers for Medicare & Medicaid Services (CMS) will ask for documentation to evaluate how that office is complying with the security standards of the Security Rule. Which of the following is not part of that evaluation? a. Administrative safeguards b. Physical safeguards c. Clinical safeguards d. Technical safeguards

c. Clinical safeguards

Some practices may choose to maintain files indefinitely and state law may vary and/or have additional requirements. Minimum requirements for records retention is ultimately governed by: a. the provider's policy. b. the state law only. c. HIPAA. d. local hospital jurisdiction.

c. HIPAA.

Folders or cards are easily filed alphabetically or numerically, but the procedure for filing reports and letters requires several steps. What is the first step in filing? a. Indexing b. Sorting c. Inspecting d. Coding

c. Inspecting

CHEDDAR is an acronym used for: a. evaluating laboratory results. b. determining which accounting method is to be used in the practice. c. retrieving patient billing information. d. conducting a patient encounter.

d. conducting a patient encounter.

You often hear the terms EMR and EHR used interchangeably, but there is a distinction. Electronic health records (EHR) refers to: a. patient records in a digital format. b. the electronic component to deal with day-to-day financial and administrative operations of a medical practice. c. software designed for monitoring insurance claims. d. the interoperability of electronic medical records, or the ability to share medical records with other health care facilities.

d. the interoperability of electronic medical records, or the ability to share medical records with other health care facilities.

"Meaningful use" refers to: a. billing practices. b. what type of labs are ordered. c. how a prescription is taken. d. the manner in which electronic health records are used

d. the manner in which electronic health records are used

privacy officer

person designated by a healthcare organization who handles and oversees the maintenance of protected health information

objective

information or symptoms that can be observed

Stage 1 (Meaningful Use) List of Eligible Professional Core objective

Implement drug-drug and drug-allergy interaction checks

HPIP

a similar system to SOAP of recording medical information about patients

Which of the following items are NOT part of a patient's demographic information? a. Lab values b. Religion c. Marital status d. Ethnicity e. Gender

a. Lab values

Since 2004, when then President George W. Bush addressed the American Association of Community Colleges and commented that the United States was behind the times regarding patients' records, the federal government has provided incentives for medical practices to convert to electronic health records. To qualify for these incentives, providers must satisfy _______________ performance measures. a. patient-centered medical home b. accountable care organization c. meaningful use d. Stage I

c. meaningful use

The S in SOAP stands for: a. subordinate. b. symptomatic. c. subjective. d. standard.

c. subjective.

No matter the reason for the requested records, a patient must provide a signed authorization before any information may be released. The authorization must specifically indicate who should receive the information and for what purpose it will be used. In the case of __________________, additional authorization is required in addition to a general release of information. a. mental health records b. substance abuse treatment c. genetic testing d. All of the above

d. All of the above

The area of HIPAA that pertains primarily to records management is: a. maintaining the privacy of health information. b. establishing standards for any electronic transmission of health information and related claims. c. ensuring the security of all electronic health information. d. All of the above

d. All of the above

documentation

refers to both the act of preparing, or the evidence created when a healthcare professional records information regarding a patient during the course of assessment and treatment

meaningful use

term is used by government agencies to refer to the way in which medical record information is employed in order to provide a means for improving patient care and patient outcomes

Stage 2 (Meaningful Use) Advance Clinical Process

More rigorous health information exchange (HIE)

Which is the third step in filing, and is done by marking the index identifier on the papers to be filed? a. Coding b. Indexing c. Inspecting d. Sorting

a. Coding

A Security Rule within HIPAA mandates that not only the privacy of medical records but also the security of the records must be guaranteed. Which of the following would not be considered one of the four core areas of compliance? a. Have policies and procedures in place to protect against every possible anticipated, known, unknown, impermissible uses, or disclosures. b. Have policies and procedures in place that identify and protect reasonably anticipated threats to the security or integrity of the information. c. Ensure confidentiality, integrity, and availability of all electronic protected health information (e-PHI) they create, receive, maintain, or transmit. d. Ensure compliance with the Security Rule in their workforce.

a. Have policies and procedures in place to protect against every possible anticipated, known, unknown, impermissible uses, or disclosures.

Another method for charting that encourages providers to include greater detail of the information obtained during the interview and examination is known by the acronym CHEDDAR. The "D's" in CHEDDAR refer to: a. the presenting problem, recorded in the patient's words. b. where results of additional testing and a comprehensive list of all medications may be placed. c. a diagnosis or assessment. d. location and assessment of pain on a scale of 1-10.

b. where results of additional testing and a comprehensive list of all medications may be placed.

When moving volumes of files and charts, to prevent back strain and other injuries, use: a. a hand truck. b. two people. c. proper body mechanics. d. a dolly.

c. proper body mechanics.

tickler file

chronologic file commonly used as a follow-up method for a particular date

You don't look well

subjective

chronologic

the arrangement of events, dates, etc., in order of occurrence

indexing

a system of cross-referencing information contained in office files so that the data may be searched using different characteristics as the query term; the second step in filing

Advantages of electronic health records include: a. eliminating the need for transcription. b. decreasing or eliminating errors related to poor or illegible handwriting. c. abolishing the need to secure patient files. d. providing a means for patients to diagnose themselves and decrease medical costs. e. a and b only.

e. a and b only.

Stage 1 (Meaningful Use) Eligible Professional Menu Set Objective

Send patient reminders per patient preference for preventive/follow-up care

One of the most widely used methods of charting, appropriate for most types of patient encounters, is the: a. CHEDDAR note b. HPIP note c. SOAP note d. POMR note

c. SOAP note

Having policies and procedures in place that identify and protect reasonably anticipated threats to the security or integrity of the information and to protect against reasonably anticipated, impermissible uses or disclosures, applies to compliance within the HIPAA: a. Safety Rule. b. Privacy Rule. c. Security Rule. d. All of the above

c. Security Rule.

The medical record: a. documents patient progress. b. verifies necessity of services to insurance billing. c. serves as a means of communication between providers. d. All of the above

d. All of the above

Think about the advantage of electronic medical records: no more losing, misfiling, or misplacing paper charts. Electronic records are not completely foolproof, however. What is a way that electronic records may go missing? a. By entering data to the wrong patient's chart. b. By scanning documents to the wrong patient's chart. c. By creating a duplicate electronic patient chart. d. All of the above.

d. All of the above.

What type of progress note is organized and entered based on where they came from, whether from a provider, laboratory, or other source? a. CHEDDAR note b. HPIP note c. SOAP note d. POMR note

d. POMR note

Regarding storing medical records, which is TRUE? a. Records must be maintained for 15 years. b. Records of deceased patients may be destroyed after a death certificate is received. c. Patient records must be stored indefinitely. d. Records may be purged on a regular basis to make room for new charts.

d. Records may be purged on a regular basis to make room for new charts.

subjective

information is supplied by the patient and includes routine information about the patient, past personal and medical history, family history, and chief complaint

The patient's skin is pale and diaphoretic, and he is grimacing

objective