Mod 115: CH. 10 Health Records

Very little statistical information can be gleaned from an EHR system. T/F?

False

The computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages. T/F?

False Both computer-based and paper-based records have advantages and disadvantages.

Color coding is used only for patients' records and not for business records. T/F?

False Color coding can be used for both medical records and business records.

Usually, more staff members are needed when an office uses an EHR system. T/F?

False EHR systems usually mean that an office can function with fewer staff members.

A standard, nationwide rule must be followed in establishing a records retention schedule. T/F?

False No standard has been established nationally for the retention of medical records.

Subjective information is that which the provider observes during the physical examination of the patient. T/F?

False Objective information is observed during the physical examination.

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. T/F?

False Records can be transferred back and forth between referring and consulting physicians through the EHR system.

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

False The EHR system is able to distinguish matching diagnosis and procedure codes.

The EMR relates to more than one healthcare organization. T/F?

False The EMR is an electronic record of health-related information about an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization.

Charge capture relates to charges for missed appointments. T/F?

False The charge capture functions can store lists of ICD and CPT codes, as well as the charges associated with procedures and supplies.

The patient owns the medical record. T/F?

False The maker of the medical record is its owner; in the physician's office, the physician is the maker/owner of patient medical records.

PHI stands for "private health information." T/F?

False PHI stands for "protected health information"

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

True

By legal definition, if it is not documented, then it did not happen. T/F?

True

HITECH Act stands for Health Information Technology for Economic and Clinical Health Act. T/F?

True

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

True

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

True

Less storage space is needed for EHR systems. T/F?

True

Numeric filing provides extra confidentiality to medical records. T/F?

True

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

True

The EHR allows access to patient information in an emergency. T/F?

True

The EHR system can allow patients to set their own appointments using the internet. T/F?

True

The patient's health record should never leave the office. T/F?

True

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

True

The three basic filing methods are alphabetic, numeric, and alphanumeric. T/F?

True

When documents are added to a patient's paper record, the most recent information should be placed on top. T/F?

True

Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files. A. Inactive B. Closed C. Active D. Dead

B. Closed

The process of moving an active file to inactive status is called: A. Coding B. Purging C. Indexing D. Conditioning

B. Purging

The physical health record belongs to the: A. All are correct B. Patient C. Insurance company D. Physician or provider

D. Physician or provider

Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology? A. Medical billing system B. Appointment scheduler C. Referral management D. Charge capture

D.Charge capture