dolhay 2

Which section of the law, commonly known as the Economic Stimulus Package, pertains to healthcare? a. ARRA b. HITECH Act c. HIPAA d. None of the above

B. HITECH Act Pg. 189

Which of the following indirect filing systems is used by a majority of large clinics and hospitals? a. Alphabetic filing b. Numeric filing c. Subject filing d. Color-coded filing

B. Numeric filing Pg. 205

Which of the following health information exchanges allows providers to find and/or request information on a patient from other providers? a. Direct exchange b. Query-based exchange c. Consumer mediated exchange d. All of the above

B. Query-based exchange Pg. 197

Information that is gained by questioning the patient or that is taken from a form is called ________________ information. a. confidential b. subjective c. objective d. necessary

B. Subjective Pg. 183

An aggregate of activities designed to ensure adequate quality is called quality control.

True Pg. 182

By legal definition, if it isn't charted, then it didn't happen.

True Pg. 183

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

True Pg. 187

Because some physicians' handwriting is illegible, the electronic health record helps guarantee that the documents will be readable even several years after their creation.

True Pg. 189

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

True Pg. 189

In Subtitle D of the HITECH Act, the privacy and security concerns related to the electronic submission of health information are addressed.

True Pg. 189

Both the physician and staff members must receive training in the use of the EHR system

True Pg. 190

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

True Pg. 190

The EHR allows access to patient information in an emergency.

True Pg. 190

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

True Pg. 191

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

True Pg. 191

An electronic health record system conceivably could hold all the patients seen over the life of a physician's practice.

True Pg. 194

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

True Pg. 197

Outguides are heavy guides used to replace a folder that has been removed temporarily.

True Pg. 202

Numeric filing provides extra confidentiality to medical records.

True Pg. 205

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

True Pg. 205

Brochures are helpful for explaining a new EHR system to patients.

True Pg. 207

Physicians can expect reductions in the amounts that they are paid from Medicare and Medicaid if they are not in compliance by 2015.

True Pg. 189

The American Recovery and Reinvestment Act of 2009 is commonly known as the Economic Stimulus Package and was meant to promote economic recovery.

True Pg. 189

PHI stands for "private health information."

False; "protected health information" Pg. 189

Medical records offer protection to the physician during legal proceedings if they are accurate and complete.

True Pg. 183

Who is the legal owner of the information stored in a patient's record? a. The patient b. The physician or agency where services were provided c. The patient's insurance company d. Both the patient and the physician

B. The physician or agency where services were provided Pg. 188

The "E" entry in the SOAPER charting method means a. entry. b. evaluation. c. education. d. exclude.

C. education Pg. 197

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

False; Objective information is observed during the physical examination. Pg. 183

Files still must be purged annually when an EHR system is used.

False; Records can be kept indefinitely when an EHR system is used. Pg. 190

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

False Pg. 195

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

True Pg. 195

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

True Pg. 197

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. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second is false. d. The first statement is false; the second is true.

A. Both statements are true. Pg. 188

What is the HIPAA privacy rule requirement for the retention of health records? a. HIPAA does not include requirements. b. Records must be kept for at least 10 years. c. For at least the period of the statute of limitations for medical malpractice claims d. Until the minor reaches the age of majority plus the statute of limitations

A. HIPAA does not include requirements. Pg. 195

Which EHR system backup is probably the least trouble and requires the least amount of hardware? a. Online backup system b. External hard drives c. Full server backup d. Thumb drive backup

A. Online backup system Pg. 194

The process of moving an active file to inactive status is called a. purging. b. indexing. c. coding. d. conditioning.

A. Purging Pg. 195

How would you properly index the name "Amanda M. Stiles-Duncan" for filing? a. Stilesduncan, Amanda M. b. Stiles Duncan, Amanda M. c. Duncanstiles, Amanda M. d. Duncan, Amanda M. Stiles

A. Stilesduncan, Amanda M. Pg. 205

What is the most important reason for telling the physician when a charting error is discovered later? a. To protect the patient's health and well-being b. To protect the medical assistant's job c. To make sure the medical assistant is not accused of making the error d. To keep the patient from discovering the error

A. To protect the patient's health and well-being Pg. 199

Advantages of the EHR system include a. ability of the physician to see more patients in a day. b. cost of implementation. c. possibility of a breach of confidentiality. d. concern of patients over privacy.

A. ability of the physician to see more patients in a day. Pg. 189

A correction to a medical record can be made by a. drawing a line through the entry and writing the correct information. b. whiting out the entry and writing over it. c. rewriting the entire page of progress notes with the error corrected. d. All of the above

A. drawing a line through the entry and writing the correct information. Pg. 199

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

False; An incredible amount and variety of statistics can be calculated from an EHR system. Pg. 190

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

False; Both computer-based and paper-based records have advantages and disadvantages. Pg. 190

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

False; Color coding can be used for both medical records and business records. Pg. 206

Less storage space is needed for EHR systems.

True Pg. 190

Who ultimately decides whether a medical record can be released? a. The physician b. The office manager c. The medical assistant d. The patient

D. The patient Pg. 207

Which of the following is not objective information? a. Progress notes b. Family history c. Diagnosis d. Physical examination and findings

B. Family History Pg. 187

The "R" entry in the SOAPER charting method means a. rationale. b. response. c. repeat. d. reinforce.

B. response Pg. 197

Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to a. make frequent eye contact with the patient and smile. b. type in every word the patient says. c. make sure the patient is not hiding any part of the health history. d. sit in a chair across from the patient so that the person cannot see the screen.

A. make frequent eye contact with the patient and smile. Pg. 193

The most frequently used follow-up method is a a. tickler file. b. transitory file. c. practice management file. d. None of the above

A. tickler file. Pg. 207

How are corrections made to the electronic health record? a. Corrections can be noted by hand and entered, as long as they are initialed. b. A new entry or addendum must be added close to the original entry with the correct information and then initialed. c. The incorrect entry is deleted and the new one is written in. d. The error is brought to the attention of the office manager for instructions on how to correct it.

B. A new entry or addendum must be added close to the original entry with the correct information and then initialed. Pg. 199

Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology? a. Appointment scheduler b. Charge capture c. Referral management d. Medical billing system

B. Charge capture Pg. 192

Which statement is not accurate about correcting charting errors? a. Insert the correction above or immediately after the error. b. Draw two clear lines through the error. c. In the margin, initial and date the error correction. d. Do not hide charting errors.

B. Draw two clear lines through the error. Pg. 199

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) a. EMH. b. EHR. c. EMR d. PHI.

B. EHR Pg. 188

In a paper record, which of the following is never an acceptable method of correction to a handwritten entry? a. Draw a line through the error. b. Erase or use a correction fluid. c. Insert the correction above the error. d. Write initials or signature below the correction and date. e. All of the above are acceptable.

B. Erase or use a correction fluid. Pg. 199

How can the EHR function to best help improve a facility's appointment show rate? a. The system can matrix the schedule with input from a staff member. b. The system can be programmed to initiate reminder and confirmation calls to patients. c. The system will allow searches for patient appointments based on a few parameters. d. The system can generate a list of the confirmed appointments.

B. The system can be programmed to initiate reminder and confirmation calls to patients. Pg. 190

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 Pg. 195

A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files is called a(n) _____________ system. a. shelf filing b. indirect filing c. direct filing d. shingling

B. indirect filing Pg. 205

In most cases, does the electronic health record system require more or less storage space than a paper filing system? a. More b. Less c. About the same

B. less Pg. 190

A set of physical properties, the values of which determine characteristics or behavior, is called a. interoperables. b. parameters. c. informatics. d. gauges.

B. parameters. pg. 182

The physical medical record belongs to the a. patient. b. physician or provider. c. insurance company. d. All of the above

B. physician or provider. Pg. 207

A strong, highly glazed composition paper or heavy card stock is called a. augment. b. pressboard. c. microfilm. d. shingle.

B. pressboard. Pg. 182

The newest component used today to complete transcription and authenticate records is __________ software. a. voice-activated b. voice recognition c. voice registry d. voice-controlled

B. voice recognition Pg. 199

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) a. PHR. b. EHR. c. EMR. d. PHI.

C. EMR Pg. 188

Which of the following is not an advantage of a numeric filing system? a. It allows periodic expansion without shifting folders. b. It provides additional confidentiality to the chart. c. Filing activity is greatest when the system is initiated. d. It saves time in record retrieval and re-filing.

C. Filing activity is greatest when the system is initiated. Pg. 205

What is one of the benefits of using a paper health record? a. Multiple users can access the record at the same time b. Fewer errors c. Good evidence of patient care d. Links clinical information for billing purposes e. All of the above

C. Good evidence of patient care Pg. 183

Improved outcomes is part of which of the stages of meaningful use? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

C. Stage 3 Pg. 189

Which statement is not true regarding the reasons for keeping accurate medical records? a. The medical record provides critical information for other caregivers. b. Effects of various treatments can be tracked and statistics gleaned from them. c. The patient's family may want to examine the records and correct errors. d. Accurate records are vital for financial reimbursements.

C. The patient's family may want to examine the records and correct errors. Pg. 183

Continuity of care means a. an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries. b. a formal examination of an organization's or individual's accounts. c. medical attention that continues smoothly from one provider to another so that the patient receives the most benefit. d. granted or endowed with a particular authority.

C. medical attention that continues smoothly from one provider to another so that the patient receives the most benefit. Pg. 183

The medical record should be released only with a a. verbal order from the physician. b. written order from the physician. c. written release from the patient. d. verbal order from the office manager

C. written release from the patient. Pg. 195

Disadvantages of the EHR system include a. cost. b. training time. c. learning curve. d. All of the above

D. All of the above Pg. 190

Medical assistants can encourage other staff members during a conversion to an electronic health record system by a. assisting whenever possible as co-workers perform their duties. b. welcoming a call for help if asked to provide assistance. c. working as a team to help clarify confusing technical instructions. d. All of the above

D. All of the above Pg. 190

Many healthcare facilities now use voice recognition software for transcription. The system can be used to dictate which types of reports? a. Progress notes b. Letters c. E-mails d. All of the above

D. All of the above Pg. 199

The medical assistant should consider which of the following when selecting filing equipment? a. Fire protection b. Cost of space and equipment c. Confidentiality requirements d. All of the above

D. All of the above Pg. 201

Which of the following are common types of filing equipment found in a medical office? a. Rotary circular files b. Lateral files c. Automated files d. All of the above

D. All of the above Pg. 201

The advantages of using the color-coding filing system are the following: a. a misfiled record is easily spotted even from a distance. b. the use of color visually restricts the area of search for a specific record. c. you can use either the alphabetic or numeric color-coding system. d. All of the above

D. All of the above Pg. 206

Which of the following is not an advantage of color-coded filing systems? a. Patient charts can be found quickly. b. It is easy to tell when a file has been misplaced. c. Patient charts can be re-filed quickly. d. All of the above are advantages.

D. All of the above are advantages. Pg. 206

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? a. Dr. Jill Freeman b. Freeman, Dr. Jill c. Freeman, Jill d. Freeman, Jill M.D

D. Freeman, Jill M.D Pg. 205

HIPAA recommends that physicians keep the records on patients for at least a. 1 year. b. 2 years. c. 3 years. d. HIPAA does not recommend a number of years.

D. HIPAA does not recommend a number of years. Pg. 195

Which of the following is not needed when describing a patient's chief complaint? a. Remedies the patient has tried to relieve symptoms b. The duration of pain c. The time when symptoms were first noticed d. How many family members are healthy

D. How many family members are healthy Pg. 186

Who is responsible for calming patients' fears and concerns about switching to an electronic medical record system? a. The physician b. The front office medical assistants c. The back office medical assistants d. The entire team at the office

D. The entire team at the office Pg. 190

Medical facilities should keep records on minors for how long? a. Indefinitely b. Until the minor is deceased c. For 10 years d. Until the minor reaches the age of majority, plus 3 years

D. Until the minor reaches the age of majority, plus 3 years Pg. 195

The preferred filing method for a physician's office is a. alphabetic. b. numeric. c. alphanumeric. d. the one most preferred by the staff

D. the one most preferred by the staff Pg. 205

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; Records can be transferred back and forth between referring and consulting physicians through the EMR system. Pg. 188

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

False; The EHR system is able to distinguish matching diagnosis and procedure codes. Pg. 192

The EMR relates to more than one healthcare organization.

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. Pg. 188

Charge capture relates to charges for missed appointments.

False; The charge capture functions can store lists of ICD and CPT codes, as well as the charges associated with procedures and supplies. Pg. 192

The patient owns the medical record.

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. Pg. 207

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

False; an office can function with fewer staff members. Pg. 189

Which of the following is not a method of organizing a medical record? a. Source oriented b. Problem oriented c. Progressively d. Chronologically

c. Progressively Pg.197