Ch. 13 - Medical Records Management

Unit 1

A unit identifies each part of a name. The key unit is also known as what?

4. Peter Lally 1. Peter J Lally 3. Peter J Lally III 2. Peter J Lally Jr.

Choose the correct filing order for the following persons. 1. Peter J. Lally 2. Peter J. Lally Jr. 3. Peter J. Lally III 4. Peter Lally

Tickler

Which of the following best describes a filing method that serves as a reminder for future actions?

Four

How many indexing units apply to the name and title, John W. Williams, M.D.?

Before

How would Henry Patrick Hays IV be filed in relation to Henry Patrick Hays Jr.?

2014

In President George Bush's 2004 Health Information Technology Plan, he included the goal that most Americans would have electronic health records by what year?

medical records

Medical facilities generate a large amount of information. The greatest bulk of it comes from what?

Provide easy retrieval, Have all documentation complete and correct, Have a format that is easily understood by all

The management of the medical record must:

Primary

The middle pair of digits in the middle-digit filing system are considered which of the following?

9

There are how many Rules to be followed when filing a patient's chart?

Problem-oriented medical record (POMR)

Which method of arranging charts uses a page that lists vital identification data, immunizations, allergies, medications, and problems?

ER

What additional letters have been added to medical facilities using the SOAP approach to charting?

Can be used by only one person at a time

What is NOT considered to be an advantage of the Manual Medical Record?

Correspondence, Lab reports, Clinical notes

What is the most common document that will be a part of the patient chart?

EHR

When EMRs from multiple sources are combined into one database for a patient, what term is used?

Use a single red line and your initials.

When an error has been made and you need to correct a medical record, what must be done?

All of the above information should not be placed on the outside of the chart (Address, Social security number, Date of birth)

When traditional paper-based charts are used, HIPAA compliance mandates no identifiable patient information should be located on the outside of the chart. This information includes all of the following except:

Patient name, Required action, Tickler date

When using a tickler file, what should be listed on the reminder?

Separate unit at the end

Which of the following best describes how titles are considered when alphabetizing and assigning units for filing order?

active

Which of the following best describes records that need to be readily accessible for retrieval of information?

identifying location of a file

Which of the following best describes the primary use of cross-reference filing?

chart removals

Which of the following best describes the primary use of out guides?

record purging

Which of the following best describes the process of sorting through records and removing those that are not active?

Full-cut folders and a color-coded label

Which of the following best describes the tab-alpha system?

Numeric

Which of the following filing systems would be most appropriate when you have a large number of patients?

Tab-beta-a

Which of the following is NOT a type of color-coding system?

horizontal

Which of the following is NOT a type of filing cabinet used in medical clinics?

check all outguides

Which of the following is NOT an appropriate action to locate missing files?

Amount of cross-referencing needed

Which of the following is NOT considered when choosing a patient filing system?

outguide

Which of the following is NOT essential equipment needed with a numeric filing system?

Geographic

Which of the following is a coding system NOT commonly used in ambulatory care centers?

Indexing units

Which of the following is a filing method used to identify and separate items to be filed in small subunits?

Out sheets

Which of the following is a filing tool used to track a patient's chart removed from the storage area?

Identify the primary filing label, Identify an alternative where one might find the file, Make a proper file to be used as the primary location.

Which of the following is a step for cross-referencing a file?

On-site assistance may be required.

Which of the following is considered a disadvantage of electronic medical records?

Person having possession

Which of the following is considered primary information found on an outguide?

Stanns Hospital

Which of the following is the appropriate indexing unit for St. Ann's Hospital?

Miscellaneous

Which of the following is the appropriate place for filing an item that does not have enough in number to warrant an individual folder?

3, 4, 2, 1, 5

Which of the following is the correct order of the procedural steps for filing patients' medical records? 1. Sort 2. Code 3. Inspect 4. Index 5. File

legal name

Which of the following is the most appropriate format for a patient's name on a medical chart?

Accession record

Which of the following is used in numeric filing as a journal or computer listing in which numbers are preassigned?

SOMR

Which of the following medical record formats does NOT contain a problem list?

They may be released without a patient's knowledge.

Which of the following statements does NOT best describe the importance of accurate medical records?

Inspect, Index, code (all of these are helpful)

Which of the following steps for filing medical documentation is NOT helpful?

It was not written down, so it did not happen.

Which of the following would apply to the legal standard if there is no written record of a temperature, a visit, a history, a physical, or a lab report?

Strict chronological arrangement

Which type of medical record has data filed strictly with the most recently charted materials at the top of the folder?

AMRA

Who is responsible for developing basic indexing rules for filing?

numeric filing

equally distributed files

numeric filing

have straight and terminal systems

alphabetic filing

labels assigned to each file

numeric filing

preserves patient confidentiality

alphabetic filing

simplest filing method

alphabetic filing

used when a limited number of files is accessed