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