Medical Records

1. Permission granted by an individual voluntarily and in his right mind is known as A. consent. B. compliance. C. standard of care. D. duty of care. Submit My Response

Consent Implied or expressed consent is the voluntary permission given by the patient for examination, testing, and treatment. Compliance is the act of following orders or doing what is expected or asked, standard of care is a set of guidelines that should be followed for each patient, and duty of care refers to a set of actions that a person is obligated to follow in order to prevent harm to others.

16. The patient who refuses to pay their medical bill at the established rate after receiving health care services is in breach of which of the following? A. HIPAA B. contract C. security D. Patient's Bill of Rights Submit My Response

Contract Most legal contracts are made up of a "Fee for Service" type agreement. Failure to pay for medical care received is a failure to comply with the obligations of a legal contract. HIPAA, security and a Patient's Bill of Rights are not legal contracts entered into by both the client and the provider for services rendered.

19. The Needlestick Safety and Prevention Act exists to protect healthcare workers from accidental exposure to A. carcinogens. B. blood borne pathogens. C. hazardous chemicals. D. biologic toxins. Submit My Response

Blood borne pathogens. The Needlestick Safety and Prevention Act requires reporting and documentation of all sharps injuries. In compliance with OSHA standards, log or report must be kept in the medical facility describing the incident, type of device, time, date, location, and follow up. This also includes minor incidents that do not result in injury or illness.

13. A phlebotomist's failure to keep any or all privileged medical information private is called A. breach of confidentiality. B. negligence. C. res ipsa loquitur. D. invasion of privacy. Submit My Response

Breach of confidentiality. Breach of confidentiality occurs when a phlebotomist fails to keep medical information private. Negligence occurs when someone is careless while caring for another person and fails to perform an action that is expected of them, therefore resulting in injury or damage. Res ipsa loquitur involves holding someone responsible and is considered negligent if any harm or injury is done under their control. An invasion of privacy means someone intrudes on the personal life of someone else without a justified reason.

20. Which of the following protects a volunteer from liability when providing emergency care in a non-healthcare setting? A. Patient's Bill of Rights B. Good Samaritan Act C. Code of Federal Regulations D. Patient Self-Determination Act Submit My Response

Good Samaritan Act The Good Samaritan Act is set in place to protect volunteers from being liable in the event of an emergency setting. The Patient's Bill of Rights is a document that shows patients what they should expect and what type of care they should receive while they are in the hospital or receiving healthcare. The Code of Federal Regulations is a list of codes that explain the rules set in place by the government. The Patient Self-Determination Act requires healthcare professionals to provide information about advanced directives when a patient is admitted to the hospital.

7. A patient with Medicaid presents to the provider's office requesting copies of medical records. The patient presents a valid ID and signs a consent form and the medical office assistant charges the patient $10.00 for the copies. Which of the following is true regarding this charge? A. A provider cannot charge any patient for medical records. B. A provider can charge for the medical records because the records belong to the provider. C. A provider cannot charge a Medicaid patient for medical records. D. A provider can charge for medical records if record reproduction is covered under the patient's insurance. Submit My Response

A provider can charge for the medical records because the records belong to the provider.:::: In most states it is legal for a doctor or healthcare facility to charge a medical records copy fee. The medical records copy charge is usually regulated by the laws of the state where the doctor or healthcare facility is located. Copying medical records requires time from the doctor or hospital staff to fulfill a request for health information. Charging a fee to copy medical records offsets the cost incurred by the doctor or healthcare facility.

8. A patient presents to the outpatient department for a chest x-ray and sputum culture. The patient was referred from his primary care physician for a long-term cough. The resident physician provides the initial interpretation of the x-ray film and states "pneumonia" and signs the report. Seven days later the sputum culture indicates a streptococcal infection. Which of the following actions should the medical office assistant take? A. Have the resident physician sign the original note and make an internal change within the medical record. B. Create a new medical narrative that would take the place of the original, along with an addendum. C. Allow the note to stand because documentation continuity allows for effective treatment of the patient. D. Create an addendum because the new information must be connected to the original note. Submit My Response

Create an addendum because the new information must be connected to the original note. An addendum should be generated and connected to the original note in the medical record. If the medical record entry is inaccurate or incomplete; adding an amendment, correction or addendum maintains the integrity of the record.

22. The physician has a public duty to fulfill state reporting requirements in which of the following circumstances involving a patient? (Select the four (4) correct answers.) A. death B. stab wound C. sexually transmitted infection D. schedule V controlled substance abuse E. elder abuse Submit My Response

Death, stab wound, sexually transmitted infection, elder abuse When a patient dies, the cause of natural death (if known) and physician's signature are recorded. In addition, a report must be filed for births, specified communicable diseases, reportable injuries (ex. gunshot wound, stabbing, animal bite), and any type of suspected or confirmed abuse. The medical assistant often assists with the reporting process, and should become familiar with state requirements.

5. In which of the following medical record categories should the medical office assistant file a patient's electrocardiogram result? A. therapeutic service documents B. diagnostic procedure documents C. laboratory documents D. encounter documents Submit My Response

Diagnostic procedure documents An electrocardiogram (ECG) is a diagnostic procedure and would be filed accordingly. The other documents would be entered into the medical record but they are not part of a diagnostic procedure. Coding and proper documentation helps to prove the medical necessity of treatment. The accuracy and adequacy of documentation greatly affects any medical billing.

6. Which of the following medical reports includes patient demographic information, dates of hospitalization, reason for hospitalization, brief history, significant findings from examinations and tests, course of treatment, final condition of the patient, and final diagnosis? A. discharge summary report B. pathology report C. history and physical report D. operative report Submit My Response

Discharge summary report A discharge summary report is a clinical report prepared by medical practitioners when a patient is ready for discharge from a hospital or care facility. The discharge summary informs outpatient medical or mental health workers about services provided by the inpatient facility: admitting complaint, diagnoses, medications, treatments, and recommendations for outpatient follow-up services. The other reports mentioned are a part of the DSR.

18. An adolescent who has been legally granted the status of adulthood and no longer under the care of a parent or guardian is known as which of the following? A. emancipated minor B. age of majority C. ward of the state D. guardian ad litem

Emancipated minor An emancipated minor is defined by individual state laws, usually meeting one or more conditions: marriage, military duty, being self-supporting, and living separately from parents/guardian. When someone reaches the age of majority, they have reached legal age. A ward of the state or one with a guardian ad litem, is still under the care of a legally appointed person or entity.

15. It is necessary for a medical office assistant to copy/scan picture identification and obtain required signatures A. to bill the insurance company. B. to comply with HIPAA regulations. C. to confirm and protect the patient's rights. D. to ensure and verify proper documentation. Submit My Response

Ensure and verify proper documentation. Medicine is a highly regulated practice. It is necessary to verify and ensure proper identification and documentation at all times. This is why it is important to have on file a picture identification and signature representing each patient. It is still important to bill insurance companies appropriately, but that will be associated with the insurance card presented by the patient or legal guardian. Every patient should rights protected and HIPAA regulations followed at all times, regardless of a signature.

10. Which federal regulation requires medical professionals to protect the privacy and confidentiality of patients' health information? A. OSHA B. CLIA C. CMS D. HIPAA Submit My Response

HIPAA HIPAA (Health Insurance Portability and Accountability Act) requires medical professionals to protect the confidentiality of patients' health information. OSHA (Occupational Safety and Health Administration) is an agency that makes sure safety is being enforced in the workplace. CLIA (Clinical Laboratory Improvement Amendments) are a set of rules and standards used to make sure quality laboratory testing is being done. CMS (Centers for Medicare and Medicaid Services) is an agency put in place to provide standards for health insurance.

11. In 1996, Congress passed which of the following statutory laws to ensure that patient information and records will be kept confidential? A. ADA (Americans with Disabilities Act) B. PPACA (Patient Protection and Affordable Care Act) C. HIPAA (Health Insurance Portability and Accountability Act) D. FMLA (Family and Medical Leave Act) Submit My Response

HIPAA (Health Insurance Portability and Accountability Act)

9. The medical assistant is contacting a patient to request they make a follow-up appointment. Which of the following forms should the medical assistant verify prior to leaving this message on the patient's voicemail? A. Consent to Treat B. HIPAA Confidentiality and Privacy C. Assignment of Benefits D. Durable Power of Attorney for Healthcare Submit My Response

HIPAA Confidentiality and Privacy The patient indicates communication preferences and requests on the HIPAA form. Consent to Treat deals with accepting medical care, Assignment of Benefits is an arrangement by which a patient requests that their health benefit payments be made directly to a designated person or facility, such as a physician or hospital and the DPA is a type of advance medical directive in which legal documents provide the power of attorney to another person in the case of an incapacitating medical condition.

4. Which of the following is a characteristic of an EMR system used by a medical office? A. It is the principal medical record used in healthcare facilities. B. It incorporates computer systems from many different vendors. C. It requires clinicians to use an interface to view data from different systems. D. It must be accessible to any specialists who are also treating the patient. Submit My Response

It is the principal medical record used in healthcare facilities. An electronic medical record (EMR) is kept in a computer system and serves as the principle medical record for each patient. There are numerous vendors that provide EMR systems, so systems will vary among medical practices. Each medical practice has its own electronic system that is accessible solely by that practice. An electronic medical record (EMR) is the principal medical record method used in most current healthcare facilities. It contains the patient's demographics (name, age, address), a record of medical treatment received, possible allergies and medication history.

12. A patient calls the office asking for ECG test results. The individual answering the phone should A. verify the patient's first and last name before giving the patient results. B. verify the patient's first and last name, date of birth, and social security number before giving results. C. let the patient know that the results cannot be discussed over the phone. D. make an appointment for the patient to meet with the ECG technician to discuss results.

Let the patient know that the results cannot be discussed over the phone.:::: Certain test results are considered sensitive and require consultation with, or explanation from, the physician or other licensed professionals. ECG results fall into this category and cannot be given over the phone. If a test result falls into the category that can be given over the phone, the identity of the person receiving the information must be verified. The person should be able to provide a first and last name, date of birth, and social security number. The patient would meet with the physician (not the ECG technician) to discuss the results.

14. A patient's blood work came back with a diagnosis of an infection. Which finding would also be seen on the patient results? A. leukocytes B. erythrocytes C. thrombocytes D. platelets Submit My Response

Leukocytes The body would respond to an infection by producing leukocytes (white blood cells that help mount an immune response to fight infection). Thrombocytes (platelets) are associated with clotting. Erythrocytes (red blood cells) carry oxygen.

23. Purging is the act of A. Moving a file from active to inactive B. Moving a file to storage C. Shredding a file D. Scanning a file into EHR Submit My Response

Moving a file from active to inactive Purging is the act of cleaning out inactive or obsolete records or data from the set of active files (whether physical or computer-based) for archiving or destruction (deletion).

21. The mutual recognition of a license from one state to another is known as which of the following? A. informed consent B. reciprocity C. revocation D. implied consent Submit My Response

Reciprocity Reciprocity is the practice of exchanging things with others for mutual benefit, especially privileges granted by one country or organization to another. It allows for provider privileges across state lines. Informed consent is permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits and Implied Consent is inferred from a person's actions and the facts and circumstances of a particular situation (or in some cases, by a person's silence or inaction). Revocation refers to the cancelling or annulment of something by some authority.

17. Which of the following regulates the time frame allowed for filing a lawsuit? A. standard of proof B. statute of limitations C. arbitration D. mediation Submit My Response

Statute of limitations The Statute of Limitations sets the maximum time after an event, illness, or injury that legal proceedings may be initiated. Typically, 2-years for medical malpractice, but varies by state and type of litigation. Arbitration (the use of an arbitrator to settle a dispute) and Mediation (intervention in a dispute in order to resolve it) are not time frame related legal practices. Standard of Proof involves the degree of evidence necessary to establish proof in criminal or civil proceedings.

3. Which of the following is the role of a medical transcriptionist in the health care setting? A. converting paper-based records into electronic medical records B. retrieving information from medical records C. transforming medical information into a permanent document D. editing electronic medical records

Transforming medical information into a permanent document::::: Medical transcriptionists transform medical information, whatever the format, into a permanent record whether electronic or paper to document the care a patient receives in the healthcare environment.

2. A medical office assistant's family asks to see the medical information of her brother-in-law who has just been brought into the emergency room. If the medical office assistant accesses the information it is A. appropriate because she is a family member. B. a violation of the Privacy Rule. C. permissible because she is an employee. D. prosecutable as fraud. Submit My Response

Violation of the Privacy Rule. The HIPAA Privacy Rule provides federal protections for health information held by medical facilities and gives patients rights with respect to that information. Disclosure to anyone other than the patient or healthcare provider is a violation of the Privacy Rule. The Privacy Rule is balanced so that it permits the disclosure of health information, within the healthcare setting, for access to the needed information for patient care and other important purposes.