ch.19
which of the following are common types of filing equipment found in a medical office
all of the above - rotary circular files -horizontal shelf files -automated files
the medical assistant should consider which of the following when selecting filing equipment
all of the above -fire protection -cost of space and equipment -confidentiality requirement
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 -progress notes -letters e-mails
a filing system that uses a combination of letters and numbers is said to be _______
alphanumeric
continuity of care means
another so that the patient receives the most benefit
the process of moving an active file to inactivate status is called
purging
_______ of an entry in a medical record is never acceptable
obliteration
medical facilities should keep records on minors for how long
until the minor reaches the age of majority, plus the statue of limitations
To be granted or endowed with a particular authority or right is to be
vested
the type of electronic record of health related information about a patient that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization is a
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
EMR
An electronic record of health-related information that can be drawn from multiple sources and is managed, shared, and controlled by the individual is a
PHR
the physical medical record belongs to the
Physician or provider
PHI stands for
Protected Health Information
how would you properly index the name " Amanda M stiles-Duncan" for filing
Stilesduncan, amanda M.
How are corrections made to the electronic health record?
a new entry or addendum must be added close to the original entry with the correct information and then initialed
the advantages of using the color-coding filing system are the following:
all of the above
In a paper record, which of the following is never an acceptable method of correction to a handwritten entry?
erase or use a correction fluid
most experts agree that the EHR system will help reduce medical _______
errors
Very little statistical information can be gleaned from an EHR system. T or F
false
charge capture relates to charges for missed appointments T or F
false
the EHR system is not capable of telling whether a certain procedure matches a specific diagnosis code T or F
false
which of the following is NOT objective
family history
a filing system that requires the use of aplabetic cross- reference to locate specific files is called a(n) ________- system
indirect filing
perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to
make frequent eye contact with the patient and smile
who ultimately decides whether a medical record can be released
the patient
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 stored in patients record
the physician or agency where services were provided
the most frequently used follow up method is a
tickler file
The software of an EHR system can be designed to be compatible with a medical specialty office, such as pediatrics or oncology. T or F
true
the EHR system should be backed up
daily
a process of electronic data entry of the providers instructions for the treatment of patients is called ______
CPOE
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
what is the HIPAA privacy rule requirement for the retention of health records
HIPAA does not include requirements
HIPAA recommends that physicians keep the records on patients for at least
HIPAA does not recommend a number of years
the EHR systems ______ component allows the physicians staff to communicate with and send claims electronically yo insurance companies
medical billing
which of the following indirect filing systems is used by a majority of large clinics and hospitals
numeric filing
which EHR system back up is probably the least trouble and requires the least amount of hardware
online backup system
a rule that controls how something is done is called
parameters
which of the following is NOT a method of organizing a medical record
progressively
the type of medical record organization that has the following four components; database, problem list, treatment plan, progress notes
protected health information
the ______ diagnosis is temporary and is made before test results have been received
provisional
for record to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written. the best indication of this is the providers signature or initials on the typed or EHR entry
both statements are true
which of the following functions of an electronic record can store lists of billing codes and current procedural terminology `
charge capture
the concise account of the patients symptoms in his or her own words is the _______
chief complaint
files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called ______ files
closed
when a patient is transferred from one facility to another, _______ of care ensures that no lapses in treatment occur and that transitions are smooth
continuity
A correction to a medical record can be made by
drawing a line through the entry and writing the correct information
which of the following ois NOT needed when describing a patients chief complaint
how many family members are healthy
Using EHR's for e-prescribing and CPOE will meet the requirements of
meaningful use
a process to ensure the reliability of test results often using manufactured samples with known values is known as
quality control
a (n) ________ schedule is a plan for keeping and purging medical records
retention
the type of medial record organization that has observations and data categorized in sections such as; provider, laboratory, radiology, hospital, and consultations
source- oriented
information that is gained by questioning the patient or that is taken from a form is called ______ information
subjective
information contained in an electronic health record usually can be accessed from several different physical places T or F
true
the patient portals can allow patients to set their own appointments using the internet T or F
true
the medical record should be released only with a
written release from the patient
