CH 11
Which statement is not true regarding the reasons for keeping accurate medical records?
The patient's family may want to examine the records and correct errors.
The newest component used today to comple transcription and authenticate records is
voice recognition
The medical record should be released only with a
written release from the patient.
Which statement is jot accurate about correcting charting errors?
Draw two clear lines through the error.
The type of electric record of health-related informstion about a patient that conforms to nationally recognized interoperability standards and can be created,managed, and consulted by authorized clinicians and staff from more than one healthcare organization is a(n)
EHR
Which of the following is not needed when describing a patient's chief complaint?
How many family members are healthy
Which of the following is not a method of organizing a medical record?
Progressively
How would you properly index the name "Amanda M. Stiles-Duncan" for filing?
Stilesduncan, Amanda M.
Who ultimately decidez wether a medical record can be released?
The patient
Medical facilities should keep records on minors for how long?
Until the mirror reaches the age of majority, plus 3 years
Advantages of the EHR system include
ability of the physician to see more patients in a day.
Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called __________ files.
closed
A correction to a medical record can be made by
drawing a line through the entry and writing the correct information.
The "E" entry in the SOAPER charting method means
education.
A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files id called a(n) _________ system.
indirect filing
Continuity of care means
medical attention that continues smoothly from one provider to another so that the patient receives the most benefit.
The most frequently used follow-up method is a
tickler file.
Disadvantages of the EHR system include
All of the above
Many healthcare facilities now use a voice recognition software for transcription. The system can be used to dictate which types of reports?
All of the above
The advantages of using the color-coding filing systen are the following:
All of the above
The medical assistant should consider which of the following when selecting filing equipment?
All of the above
Which of the following are common types of filing eauipment 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 are advantages
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.
How would you properly index the name "Jill Freeman, M.D." for filing 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.
Who is the legal owner of the information stored in a patient's record?
The physician or agency where services were provided
What is the most important reason for telling the ohysician when a charting error is fiscovered later?
To protect the patient's health and well-being
A ser of physical properties, the values of which determine characteristics or behaviour, is called
parameters
The physical medical record belongs to the
physician or provider
A strong, highly glazed composition paper or heavy card stock is called
pressboard
The process of moving an active file to inactive status is called
purging
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 methid for a physician's office is
the one most preffered by the staff