week 7 health records quiz
A patient's relative asks for the patient's information. What should the medical assistant do?
Ask the person to get written consent from the patient. Rationale A medical assistant must never reveal the details of a patient's medical care even to close relatives, unless there is written consent from the patient to do so. Therefore the medical assistant should ask the person to get written consent or permission from the patient. The information in the medical records is the sole right of the patient, and consent from the patient is enough for the disclosure. As the provider has no right to the information in the medical record, written consent from the provider is not required. The attorney has no role in the disclosure of patient information to a relative. Written consent is a mandate; faxed or mailed consent is usually not accepted. Text reference: p. 250
How is the name of a married woman, "Mary Doe," whose husband's name is "John L." indexed during record filing?
Doe, Mary (Mrs. John L.) Rationale Doe, Mary (Mrs. John L.) is the correct form of indexing this name because for indexing the name of a married woman, her husband's surname, her given name, and her middle name are considered. No other options present the right from for indexing. Doe, Mary and Mary, Does do not indicate that the woman is married. If the woman's first is unknown, her name is indexed as Doe, Mrs. John L. Text reference: p. 258
Which action would a medical assistant take if a patient worries an unauthorized person will access his or her information in the electronic medical record (EMR)?
Explain to the patient that access to the EMR us restricted. Rationale Text reference: p. 261-262
Which filing system can be expanded without relocating all of the other files?
Numeric Rationale An advantage of numeric filing is that it allows unlimited expansion without periodic shifting of folders, and shelves usually are filled evenly. Alphabetic filing is a simple, traditional filing system in which documents are filed in alphabetic order. An alphanumeric system is a combination of the alphabetic and numeric filing systems together. Color-code filing uses color to file. Text reference: p. 259
Which file would immediately precede a file numbered "02 00 02" when a medical record has been filed in the terminal digit system?
01 00 22 Rationale 01 00 22 will be the file immediately preceding the desire file 02 00 22. In a typical terminal system, the arrangement is read from right to left.
In which scenario would the active file of a patient be converted to a closed file?
A patient is discharged from the hospital. Rationale A closed file contains the records of a patient who has died or has terminated treatment from the provider. When a patient is discharged from a hospital, his or her medical records are placed in a regular active file. An inactive file contains the records of a patient who approaches the provider after a long period. Active files include records of patients who are currently receiving some treatment from the provider. They include the treatment and side effects due to the treatment. Text reference: p. 250 Test-taking tip: If you can eliminate any responses as incorrect based on your knowledge, you will not be guessing randomly but will be exercising "informed guessing."
How are the documents in problem-oriented medical records grouped?
According to the patient's particular problems Rationale Problem-oriented medical records are organized according to the patient's particular problems. Documents in a problem-oriented medical record are not grouped geographically. In a problem-oriented medical record, documents are not grouped by type of services that were provided. Documents filed in reverse chronologic order without being grouped together are not an example of problem-oriented medical record. Text reference: p. 252 Test-taking tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.
Which method of filing is the simplest and most common?
Alphabetic Rationale Alphabetic filing is the oldest, simplest, and most commonly used system. The tickler file is a chronologic file used as a reminder that something must be dealt with on a certain date. A numeric system is an indirect filing method that is only used if there are more than 5000 records involved. Subject filing is used for generic correspondence and can incorporate both alphabetic or alphanumeric filing systems. Text reference: p. 259
Which is true regarding the use of electronic medical records (EMR)?
Authorized clinicians and staff of the facility can view the recorded patient information. Rationale The electronic medical record (EMR) is an easy way to access the records of patients. Authorized staff and providers within the same organization who have login access can view the records and record information. The EMR contains a patient portal, which will permit a patient to view his or her own records, but not the records of any other patients, including family members unless they are authorized to do so. The personal health record deals with the information of a patient, which a single individual creates, controls, and manages. Authorized staff from more than one organization can view the electronic health record information but not the electronic medical record. Text reference: p. 245-246
Which function of electronic medical records allows the storage of a list of billing codes as well as charges associated with procedures, supplies, and laboratory tests?
Charge capture Rationale Charge capture is a capability within the electronic medical record that stores a list of billing codes as well as charges associated with procedures, supplies, and laboratory tests. A patient portal can be added to the system functions, such as setting appointments. Eligibility verification is an electronic medical record billing system that can perform online verification of insurance eligibility and can capture demographic data. Laboratory order integration is a feature that allows the user to interact with outside laboratories to order tests and receive laboratory results and add them to patients' records. Text reference: p. 247
Which actions can a patient in the patient poral of the electronic medical record (EMR)?
Download immunization records. Fill out a New Patient form. Send a message to the healthcare provider Rationale A patient can use the patient portal part of an EMR to download immunization records, fill out forms, and communicate with the healthcare provider. A patient does not upload lab results or submit prescriptions through the EMR; those are actions done my medical assistants and healthcare providers. Text reference: p. 246 Test-taking tip: Be alert for details about what you being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.
Which action is acceptable when correcting a documentation error in a paper chart?
Draw a single line through the error on a paper record. Rationale Text reference: p. 254
What is the advantage of utilizing a color-coding system over other filing systems?
Easy spotting of misplaced records Rationale The distinct advantage of the color-coding filing system is that misplaced records are easily spotted. Color-coding of patients' charts restricts the vision to a particular color of search and also helps in easily spotting misplaced files based on the improper color arrangement. Sequential placement and easy recovery of the records are possible with the color-coding filing process, but these can be done even with the alphabetical or numerical system of filing. Unlimited expansion of the filing process using color coding is not possible as here are not many distinguishing colors. It might be helpful if used along with other systems of filing. Text reference: p. 260
Which electronic information system can be accessed by authorized individuals from more than one healthcare organization?
Electronic Health Record(EHR) Rationale An EMR is health-related information about a patient that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization. The EMR is health-related information about an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization. A PHR is an electronic record of health-related information about an individual that can be drawn from multiple sources but that is managed, shared, and controlled by the Patient. All of these records must conform to nationally recognized interoperability standards. The NHIN is a set of standards and policies related to the exchange of secure health information over the internet. Text reference: p. 246
Which feature of the electronic medical record (EMR) system is used while entering demographic data of a patient?
Eligibility verification Rationale The eligibility verification feature of the EMR system is used to help verify insurance eligibility and capture a patient's demographic data. The charge capture feature can be used to store lists of billing codes for different procedures. Specialty software is used to capture and process a patient's data so that the terminology and patient care treatments are compatible with the provider's specialty. The referral management feature is used to coordinate between providers for efficient copying and mailing of records. Text reference: p. 248 Test-taking tip: Multiple- choice question can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
Which backup system connects to the main computer and stores copies of the information in the electronic medical record daily?
External hard drive Rationale The external hard drive connects to the main computer and can copy the information in the EMR daily. Thumb drives are used for minimal storage and connect using a USB port. The information may be sent to an online storage facility, which requires payment of a subscription. Full server backups are performed monthly and have a large-capacity computer set aside specifically for the EMR system. Text reference: p. 249
Which privacy protections should the medical assistant institute while maintaining electronic medical records in the office?
Protecting patient's rights to confidentiality and privacy Presenting identification and authentication to access the medical records Maintaining the security and confidentiality of the patient's health information Rationale Text reference: p. 261
How are source-oriented medical records organized?
Grouped by the type of services that were provided Rationale The documents in a source-oriented medical record are grouped by the type of services that are provided. Documents in a source-oriented medical record are not grouped geographically. Organizing documents in accordance to the patient's particular problem is not an example of a source-oriented medical record. Documents stored in reverse chronologic order without grouping them is not an example of a source-oriented medical record. Text reference: p. 252 Test-taking tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.
Which term represents the acronym HIPAA?
Health Insurance Portability and Accountability Act Rationale The Health Insurance Portability and Accountability Act (HIPAA), which was enacted in 1996, is a group of laws that affect employees of healthcare facilities, insurance companies, and other covered entities and the patients they serve. The federal government required all covered entities to be in compliance with HIPAA by April 14, 2003. The other options are fictitious. Text reference: p. 245
What addresses patient privacy and electronic medical records (EMR)?
Health Insurance Portability and Accountability Act (HIPAA) Rationale The Health Insurance Portability and Accountability Act (HIPAA) protects the patient information regarding health status and healthcare provision and therefore addresses privacy in relation to use of an EMR. The Nationwide Health Information Network (NHIN) provides an interoperable infrastructure that connects organizations involved in healthcare. The American Recovery and Reinvestment Act (ARRA) is an economic stimulus package that promotes economic stimulus package that promotes economic recovery. The health Information Technology for Economic and Clinical Health Act (HITECH) provides financial incentives to achieve health efficiency for proper use of electronic health record technology. Text reference: p. 145-146
Which statement true regarding an online backup system?
It can be costly and very time involved Rationale An online backup system is a costly method that can involve a lot of time because it involves a lengthy process of contacting the company that offers it and downloading the data set. A full server backup consists of a large-capacity computer for the electronic medical record system and requires backup every month. An external hard drive like a C or thumb drive is not used for an online backup system. Text reference: p. 249-250
Which statement is true regarding an online backup system?
It can be costly and very time involved. Rationale An online backup system is a costly method that can involve a lot of time because it involves a lengthy process of contacting the company that offers it and downloading the data set. A full server backup consists of a requires backup every month. An external hard drive like a CD or thumb drive is not used for an online backup system. Text reference: p. 249-250
Which statement is true about the numeric filing system?
It is an indirect filing system. Rationale The numeric filing system is an indirect filing system as it requires a cross-reference to find a given file. As the number of files increases, more space is needed. An indirect filing system provides unlimited expansion of space without periodic shifting of folders. The numeric filing system is an indirect filing system, a cross-reference is needed to find a file. Text reference: p. 259 Test-taking tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
Which statement is true regarding the Health Information Technology for Economic and Clinical Health Act (HITECH Act)?
It provides financial incentives for certifiable use of electronic health record (EHR) technologies. Rationale The HITECH act provides financial incentives to achieve health and efficiency by the use of EHR technologies. The American Recovery Reinvestment Act is an economic stimulus package that helps to promote economic recovery. The Nationwide Health Information Network (NHIN) is an organization that provides a secure health information infrastructure to support healthcare. The regional health information organization is a health organization that brings together healthcare stakeholders in the same geographic area to improve healthcare within the community. Text reference: p. 246 Test-taking tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
How would the name "Beaumont Jean-Pierre" be indexed?
Jeanpierre, Beaumont Rationale Names such as Beaumont Jean-Pierre are indexed as "Jeanpierre,Beaumont" because, in indexing, the last name is considered first and the first name second. For a hyphenated name, the hyphen is removed during indexing. "Beaumont, Jean-Pierre," is incorrect because although the hyphen is eliminated, the last name is placed first, but the hyphen is not eliminated. In "Beaumont, Jean-Pierre," the hyphen is not eliminated, and the first name is placed at the beginning. Text reference: p. 258-259
If a patient seems hesitant or uneasy about providing his or her medical history to a medical assistant who is recording the information using an electronic medical record (EMR), which action by the medical assistant may help put the patient at ease?
Keep the computer screen in the patient's sign line. Rationale A patient may be uneasy about providing information to an medical assistant when that information is being recorded using an EMR. One way to put the patient at ease is to ensure that they are able to see the computer screen while information is being recorded. Sitting directly across a desk from the patient will likely not put the patient at ease. Asking patients for hasty decisions regarding their healthcare is never advisable because it may cause patients to feel pressured or anxious regarding any decisions that must be made. Keeping one's eyes on a computer screen and not making eye contact with the patient will not make the patient feel comfortable or more at ease. Text reference: p. 249 Test-taking tip: Try putting questions and answers in your own words to test your understanding.
Which system of recording health information is useful when a healthcare facility is experiencing extended interruptions in its electricity due to a short-circuiting on the hospital premises?
Paper medical records Rationale Paper medical records are the most useful system to record health information in this scenario as the data do not require electricity. The full server backup, external hard drive, and online backup systems are backups for the electronic medical records (EMR) and require an alternative power source. Therefore when a disaster happens on hospital premises, these backup systems are not useful for EMR. Text reference: p. 249-250
Which feature of the electronic medical record (EMR) should a parent use to print a child's immunization record?
Patient portal Rationale The patient portal feature of an electronic medical record (EMR) helps a patient access his or her record. It also helps in scheduling an appointment and printing the immunization record. Therefore the medical assistant would suggest that the parent refer to the patient portal feature of an EMR. The charge capture feature of an EMR contains the list of billing codes and the charges for different procedures. This feature of an EMR does not help in printing an immunization record. The specialty software feature of an EMR serves in capturing and processing the patient's information to make it compatible with the provider's specialty. This feature of an EMR does not help the parent to print the immunization record of a child. The EMR's prescription writer feature provides electronic prescriptions; it does not print pediatric immunization records. Text reference: p. 246
Which information is considered subjective information?
Patient's chief complaint, medical history, and family history Rationale Subjective information includes a patient's chief complaint as well as the patient's medical history and family history, which are gathered from the patient through a questionnaire before treatment. Information provided by the patient , physical examination findings, and diagnosis of the patient's condition is provided by the provider and is referred to as objective information. Text reference: p. 241
Which capability of the electronic medical record system could prevent a provider from prescribing a patient a drug to which he or she is allergic?
Prescription writing software Rationale The electronic medical record (EMR) system can produce electronic prescription writer software. The patient allergies function will alert the provider if the prescription is for a drug the patient cannot take. The system can also generate a patient information sheet on new prescriptions. Charge capture is a capability of the EMR to store a list of billing codes and charges associated with procedures, supplies, and laboratory tests. A patient portal can be added to the system that allows the patient to access medical records and perform other functions, such as setting appointments. Eligibility verification is an EMR billing system that can perform online verification of insurance eligibility and capture demographic data. Text reference: p. 247
Which section of the problem-oriented medical record (POMR) will the provider refer to if a patient is living below the poverty line?
Problem list Rationale The provider will refer to the problem list of the problem-oriented medical record (POMR) as it contains a list of every one of the patient's problems that requires management, including social and demographic issues. The database section includes the patient's profile, chief complaint, medical treatment, physical examination, and laboratory reports. A progress note is structured note in which the provider documents the patient's status of health concerning an individual problem. The treatment plan includes the therapy that is to be given to a particular patient.
Which term accurately represents the acronym "POMR"?
Problem-oriented medical record Rationale POMR stands for problem-oriented medical record, POMR does not stand for patient-oriented medical record, or problem objective medical record. Text reference: 252
Who possesses ownership of a patient's medical record?
Provider Rationale The owners of the physical medical record are the providers or the medical facility. The patient owns and has the right of access to the information in his or her medical record but does not own the physical record. The government and the court system do not possess ownership of a patient's medical record. Text reference: p. 245
Which process should a medical assistant begin once discovering the patient's medical record indicates the last visit was recorded 8 months ago?
Purging Rationale Purging is a procedure in which active files are converted to inactive files. As the patient has last visited 8 months ago, the patient's status become inactive. Vesting is giving the patient the secured right to access of older reports. It is a method of managing records or files and is not associated with the patient's frequency of visits. Gleaning is the process of gathering information about a relevant matter. It is not associated with the patient relation with the provider. Test reference: 250
Which feature of the electronic medical record (EMR) does the provider use to reduce the patient's burden in transporting medical records to referring providers?
Referral management Rationale The referral management feature of an electronic medical record (EMR) enables the provider to share the patient's information with other providers. This also helps the patient by reducing the burden of transporting medical records to those providers. The patient uses the EMR's patient feature to access the EMR; it does not help the provider share the patient's records. The charge capture feature details the costs of various services and the list of billing codes, and it prescription writer feature provides electronic prescriptions. Text reference: p. 248
How are documents stored in a source-oriented medical record (SOMR)?
Reverse chronologic order Rationale Documents in a source-oriented medical record are stored in reverse chronologic order (most recent first). Medical record documents are not stored in random order. Chronologic order is when documents in a medical record are stored oldest date first and is not used in most medical records. Documents stored in the medical record are not stored in the order that they are received. Text reference: p. 252 Test taking tip: Answer every question. A question with an answer is always wrong answer, so go ahead and guess.
What is one of the basic reasons for keeping medical records on a patient?
Serves as a legal record documenting the planning and care that the patient received Rationale The medical record serves as a legal record documenting and planning and care that the patient received. The signed consent to treat document shows that a patient has approved every test that the provider may order, but it is not a basic reason for the complete record. Office notes serve as documentation that the patient is an established patient and is not a reason for patient's medical record. The demographic information includes insurance information and is a component of the record; however, it is not an underlying reason for keeping medical records. Text reference: p. 241 Test-taking tip: Notice how the subjects of the questions are related and, through that relationship, the answers to some of the questions may be provided within other questions of the test.
Which term represents the meaning of the acronym "SOAP"?
Subjective, objective, assessment, and plan Rationale SOAP stands for subjective, objective, assessment, and plan under the POMR charting system. SOAP does not stand for subjective, objective, alternative, and plan. SOAP does not stand for subjective, objective, alternative, and procedures. SOAP does not stand subjective, objective, assessment, and procedures. Text reference: p. 252 Test-taking tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer.
Which actions fall under meaningful use of electronic health records (EHR)?
Submit clinical quality reports. Provide an e-prescription for a patient. Submit procedural codes for insurance. Rationale Meaningful use of the electronic health record (EHR) implies that healthcare providers are using the EHR technology in a manner that can be measured in quality and quantity. This meaningful use includes four main components. These components include usage of EHR technology to (1) submit clinical quality reports; (2) provide e-prescriptions for patients; (3) submit procedural and diagnostic codes for insurance; and (4) exchange all patients' health information. Meaningful use of the EHR does not include sharing patient information for marketing of the healthcare unit or only exchanging patient lab results. Text reference: p. 246 Test-taking tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some options may relate directly to the situation.
What is used to indicate that a record has been removed from the file cabinet?
Tickler Rationale To indicate that a record has been removed from the file cabinet, the medical assistant uses an out guide. The most frequently used follow-up method is a tickler file. A divider guide is used to organize filing systems. When removing a file form the file cabinet, using a paper clip is not an effective way to indicate a file has been removed. Text reference: p. 257
Which term is used to describe the medical records of patients who have not received treatment from the provider in 6 months or longer?
inactive Rationale Patients who have not been seen for 6 months or longer are considered inactive. Active patients are currently receiving treatment. Closed files are records of patients who have died, moved away, or otherwise terminated their relationship with the provider. When a provider wants to terminate a relationship with a patient, a dismissal letter will be sent to the patient, and the patient is considered dismissed by the clinic. Text reference: p. 250