NCCT-Medical Records
Which of the following protects a volunteer from liability when providing emergency care in a non-healthcare setting?
Good Samaritan Act Rationale 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.
A patient calls the office asking for ECG test results. The individual answering the phone should
let the patient know that the results cannot be discussed over the phone. Rationale 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.
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 provider can charge for the medical records because the records belong to the provider. Rationale 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.
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?
Create an addendum because the new information must be connected to the original note. Rationale 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.
Which federal regulation requires medical professionals to protect the privacy and confidentiality of patients' health information?
HIPAA Rationale 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?
HIPAA (Health Insurance Portability and Accountability Act) Rationale HIPAA is the federal Health Insurance Portability and Accountability Act of 1996. The goal is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information. The ADA prohibits discrimination against people with disabilities in employment, transportation, public accommodation, communications, and governmental activities. The PPACA or Affordable Care Act enables consumers to be in charge of their health care. Under the law, a new "Patient's Bill of Rights" gives the American people ability to make informed choices about their health. The FMLA entitles eligible employees of employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage.
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?
HIPAA Confidentiality and Privacy Rationale 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.
Which of the following is a characteristic of an EMR system used by a medical office?
It is the principal medical record used in healthcare facilities. Rationale 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.
Purging is the act of
Moving a file from active to inactive Rationale 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).
In which of the following medical record categories should the medical office assistant file a patient's electrocardiogram result?
Your answer was correct! diagnostic procedure documents Rationale 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.
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 violation of the Privacy Rule. Rationale 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.
The Needlestick Safety and Prevention Act exists to protect healthcare workers from accidental exposure to
blood borne pathogens. Rationale 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.
A phlebotomist's failure to keep any or all privileged medical information private is called
breach of confidentiality. Rationale 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.
Permission granted by an individual voluntarily and in his right mind is known as
consent. Rationale 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.
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?
contract Rationale 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.
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.)
death, stab wound, sexually transmitted infection, elder abuse Rationale 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.
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?
discharge summary report Rationale 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.
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?
emancipated minor Rationale 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.
A patient's blood work came back with a diagnosis of an infection. Which finding would also be seen on the patient results?
leukocytes Rationale 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.
The mutual recognition of a license from one state to another is known as which of the following?
reciprocity Rationale 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.
Which of the following regulates the time frame allowed for filing a lawsuit?
statute of limitations Rationale 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.
It is necessary for a medical office assistant to copy/scan picture identification and obtain required signatures
to ensure and verify proper documentation. Rationale 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.
Which of the following is the role of a medical transcriptionist in the health care setting?
transforming medical information into a permanent document Rationale 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.