Chap 10 MAST 1060

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

True

Three basic filing methods are alphabetic, numeric, and alphanumeric, true or false

True

When documents are added to a patient's paper record, the most recent information should be placed on top, true or false

True

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 when initialed

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 an

EMR

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

Erase or use correction fluid

A standard, nationwide rule must be followed in establishing a records retention schedule, true or false

False

Charge capture relates to charges for missed appointments, true or false?

False

The EHR allows access to patient information in an emergency, true or false

True

The EHR system can allow patients to set their own appointments using the internet, true or false

True

The patient's health record should never leave the office, true or false

True

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

purging

PHI stands for "private health information", true or 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 the EHR system, true or false

False

Subjective information is that which the provider observes during the physical examination of the patient, true or false

False

The EMR relates to more than on healthcare organization, true or false

False

The computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages, true or false

False

The patient owns the medical record, true or false

False

The system is not capable of telling whether a certain procedure matches a specific diagnosis code, true or false

False

Usually, more staff members are needed when an office uses an EHR system, true or false

False

Very little statistical information can be gathered from an EHR system, true or false

False

What are common types of filing equipment found in a medical office?

Rotary circular files, lateral files, and automated files

The physical health record belongs to the

physician or provider

The medical record should be released only with a

written release from the patient

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, true or false for both statements

Both statements are true

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

Charge capture

Medical charting must follow the 5Cs rule. What are three of the 5 Cs?

Concise, Complete, Clear

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

HIPAA does not include requirements

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

HIPAA foes not recommend a number of years

The R entry in the SOAPER charting method means

Response

Medical facilities should keep records on minors for how long?

Until the minor reaches the age of majority, plus the statute of limitations

Files for patients who gave died, moved away, or otherwise terminated their relationship with the physician are called _____ files

closed

A filing system in which an alphabetic cross reference must be consulted to locate specific files is called an _____ system

indirect

A correction to a medical record can be made by

Drawing a line through the entry and writing the correct information

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 form more than one healthcare organization is an

EHR

Color coding is used only for patients' records and not for business records, true or false

False

Continuity of care means

Medical attention that continues smoothly from one provider to another so that the patient receives the benefit

The most frequently used follow up method is a

Tickler file

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

By legal definition, if it is not documented, then it did not happen, true or false

True

HITECH Act stands for Health Information Technology for Economic and Clinical Health Act, true or false

True

Health records offer protection to the provider during legal proceedings if they are accurate and complete, true or false

True

Information contained in an electronic health record usually can be accessed from several different physical places, true or false

True

Less storage space is needed for EHR systems, true or false

True

Numeric filing provides extra confidentiality to medical records, true or false

True

Reverse chronologic order is where the most recent item is on the top and older items are filed farther back, true or false

True

The E entry in SOAPER charting method means

education

A provision diagnosis is not a final diagnosis and usually is made before test results are received, true or false

true