111 Chapter 11 Test

How can the EHR function to best help improve a facility's appointment show rate?

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

The process of moving an active file to inactive status is called

purging

The "R" entry in the SOAPER charting method means

response.

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

True

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

True

Which statement is not accurate about correcting charting errors?

Draw two clear lines through the error.

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)

EHR.

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

False

Numeric filing provides extra confidentiality to medical records.

True

PHI stands for "private health information."

False

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

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

False

The EMR relates to more than one healthcare organization.

False

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

False

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

False

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

False

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

False

Improved outcomes is part of which of the stages of meaningful use?

Stage 3

How would you properly index the name "Amanda M. Stiles-Duncan" for filing?

Stilesduncan, Amanda M.

What is the HIPAA privacy rule requirement for the retention of health records?

HIPAA does not include requirements.

Which of the following is not a method of organizing a medical record?

Progressively

Who is responsible for calming patients' fears and concerns about switching to an electronic medical record system?

The entire team at the office

Who ultimately decides whether a medical record can be released?

The patient

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

True

The EHR allows access to patient information in an emergency.

True

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

True

Who is the legal owner of the information stored in a patient's record?

The physician or agency where services were provided

The patient owns the medical record

false

A set of physical properties, the values of which determine characteristics or behavior, is called

parameters

The newest component used today to complete transcription and authenticate records is __________ software.

voice recognition

The medical record should be released only with a

written release from the patient

How are corrections made to the electronic health record?

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

Many healthcare facilities now use voice recognition software for transcription. The system can be used to dictate which types of reports?

All of the above

Medical assistants can encourage other staff members during a conversion to an electronic health record system by

All of the above

The medical assistant should consider which of the following when selecting filing equipment?

All of the above

Which of the following are common types of filing equipment found in a medical office?

All of the above

Which of the following is not an advantage of color-coded filing systems?

All of the above are advantages.

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. The first statement is false; the second is true.

Both statements are true.

Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology?

Charge capture

Match the PHR acronym with all the appropriate definitions. (Select all that apply.)

Conforms to nationally recognized interoperability standards Can be drawn from multiple sources Defined by the ONC Managed, shared, and controlled by the individual Electronic record of health-related information

Match the EHR acronym with all the appropriate definitions. (Select all that apply.)

Created and managed by authorized clinicians and staff from more than one healthcare organization Conforms to nationally recognized interoperability standards Electronic record of health-related information

Which of the following is not objective information?

Family history

Which of the following is not an advantage of a numeric filing system?

Filing activity is greatest when the system is initiated.

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?

Freeman, Jill M.D.

What is one of the benefits of using a paper health record?

Good evidence of patient care

HIPAA recommends that physicians keep the records on patients for at least

HIPAA does not recommend a number of years.

Which section of the law, commonly known as the Economic Stimulus Package, pertains to healthcare?

HITECH Act

Which of the following indirect filing systems is used by a majority of large clinics and hospitals?

Numeric filing

Which EHR system backup is probably the least trouble and requires the least amount of hardware?

Online backup system

The physical medical record belongs to the

Physician or provider

Which of the following health information exchanges allows providers to find and/or request information on a patient from other providers?

Query-based exchange

Which statement is not true regarding the reasons for keeping accurate medical records?

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

Medical facilities should keep records on minors for how long?

Until the minor reaches the age of majority, plus 3 years

Advantages of the EHR system include

ability of the physician to see more patients in a day

Disadvantages of the EHR system include

all of the above

Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files.

closed

A correction to a medical record can be made by

drawing a line through the entry and writing the correct information

Information that is gained by questioning the patient or that is taken from a form is called ________________ information.

subjective

The preferred filing method for a physician's office is

the one most preferred by the staff.

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)

EMR.

Match the EMR acronym with all the appropriate definitions. (Select all that apply.)

Electronic record of health-related information Created and managed by authorized clinicians and staff within a single healthcare organization

In a paper record, which of the following is never an acceptable method of correction to a handwritten entry?

Erase or use a correction fluid.

Charge capture relates to charges for missed appointments.

False

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

False

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

False

Which of the following is not needed when describing a patient's chief complaint?

How many family members are healthy

In most cases, does the electronic health record system require more or less storage space than a paper filing system?

Less

What is the most important reason for telling the physician when a charting error is discovered later?

To protect the patient's health and well-being

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

True

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

True

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

True

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

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

True

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

True

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

True

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

True

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

True

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

True

Less storage space is needed for EHR systems.

True

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

True

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

True

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

True

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

True

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

True

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

True

The "E" entry in the SOAPER charting method means

education.

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.

indirect filing

Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to

make frequent eye contact with the patient and smile.

Continuity of care means

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

A strong, highly glazed composition paper or heavy card stock is called

pressboard

The most frequently used follow-up method is a

tickler file

The advantages of using the color-coding filing system are the following:

you can use either the alphabetic or numeric color-coding system. the use of color visually restricts the area of search for a specific record. a misfiled record is easily spotted even from a distance. All of the above