chapter 12 mas 127

Who ultimately decides whether a medical record can be released?

the patient

The EHR system can allow patients to set their own appointments using the internet.

true

__________ software can be used for transcription and authentication.

voice recognition

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.

Which of the following is not an advantage of a numeric filing system?

Filing activity is greatest when the system is initiated.

Medical facilities should keep records on minors for how long?

Until the minor reaches the age of majority, plus the statute of limitations

What is the HIPAA privacy rule requirement for the retention of health records?

HIPAA does not include requirements.

The medical record should be released only with a:

written release from the patient

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

The physical health record belongs to the:

physician or provider.

Which of the following are common types of filing equipment found in a medical office?

-Automated files -Correct! All are correct -Rotary circular files -Lateral files -All are correct

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 medical assistant should consider which of the following when selecting filing equipment?

All are correct -Confidentiality require - Fire protection -Cost of space and equipment

For a 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 provider's 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

Which statement is not accurate about correcting charting errors?

Draw two clear lines through the error.

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(n):

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(n):

EMR

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

Which section of the law, commonly known as the Economic Stimulus Package, pertains to healthcare?

HITECH Act

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

Which of the following health information exchanges allows providers to find and/or request information on a patient from other providers?

Query-based exchange

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.

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

To protect the patient's health and well-being

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

closed

A standard, nationwide rule must be followed in establishing a records retention schedule.

false

Charge capture relates to charges for missed appointments.

false

Color coding is used only for patients' records and not for business records.

false

PHI stands for "private health information."

false

Physicians performing consultations still must request paper records on a patient, even if both the referring physician and the consulting physician are using an EHR system.

false

Subjective information is that which the provider observes during the physical examination of the patient.

false

The EMR relates to more than one healthcare organization.

false

The computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages.

false

The patient owns the medical record.

false

The system is not capable of telling whether a certain procedure matches a specific diagnosis code.

false

Usually, more staff members are needed when an office uses an EHR system.

false

Very little statistical information can be gleaned from an EHR system.

false

A filing system in which an alphabetic cross-reference must be consulted to locate specific files is 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.

Which of the following indirect filing systems is used by a majority of large clinics and hospitals?

numeric filing

The process of moving an active file to inactive status is called:

purging

The "R" entry in the SOAPER charting method means:

response

The advantages of using the color-coding filing system are the following:

the use of color visually restricts the area of search for a specific record. Correct Answer All are correct a misfiled record is easily spotted even from a distance. you can use either the alphabetic or numeric color-coding system.

The most frequently used follow-up method is a:

tickler file

A provisional diagnosis is not a final diagnosis and usually is made before test results are received.

true

By legal definition, if it is not documented, then it did not happen.

true

HITECH Act stands for Health Information Technology for Economic and Clinical Health Act

true

Health records offer protection to the provider during legal proceedings if they are accurate and complete.

true

Information contained in an electronic health record usually can be accessed from several different physical places.

true

Less storage space is needed for EHR systems.

true

Numeric filing provides extra confidentiality to medical records.

true

Reverse chronologic order is where the most recent item is on the top and older items are filed farther back.

true

The EHR allows access to patient information in an emergency.

true

The patient's health record should never leave the office.

true

The three basic filing methods are alphabetic, numeric, and alphanumeric.

true

When documents are added to a patient's paper record, the most recent information should be placed on top.

true

The software of an EHR system can be designed to be compatible with a medical specialty office, such as pediatrics or oncology.

true.