CH 10 Study Guide

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

False

Charge capture relates to charges for missed appointments. True False

False

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

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. True False

False

The patient owns the medical record. True False

False

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

False

By legal definition, if it is not documented, then it did not happen. True False

True

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

True

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

True

The EHR system can allow patients to set their own appointments using the internet. True False

True

The patient's health record should never leave the office. True False

True

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

True

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

c. HIPAA does not include requirements.

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 are correct

b. Query-based exchange

Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files. a. dead b. closed c. inactive d. active

b. closed

The physical health record belongs to the: a. patient. b. physician or provider. c. insurance company. d. All are correct

b. physician or provider.

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

c. Freeman, Jill M.D.

The most frequently used follow-up method is a: a. tickler file. b. transitory file. c. practice management file. d. None are correct

Tickler file

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

True

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

a. EHR.

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

b. HITECH Act

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

b. Progressively

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 keep the patient from discovering the error c. To make sure the medical assistant is not accused of making the error d. To protect the medical assistant's job

a. To protect the patient's health and well-being

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 are correct

b. Erase or use a correction fluid.This answer is correct.

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

b. Filing activity is greatest when the system is initiated

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

c. How many family members are healthy

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 are correct

d. All are correct

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

d. EMR.

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

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

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

d. response.