Medical Record

What does EMR stand for?

Electronic Medical Record

A patient's medical information can be released to anyone as long as the physician gives written permission.

False

An audit is the throwing away of a facility's records and supporting documents.

False

What do patients have the right to do to their medical records?

All of the above

Which of the following is an advantage of electronic medical records? They are quickly available in emergencies. They are legible and organized. They do not require much storage space. They allow multiple users to view files. All of the above

All of the above

Which of the following is NOT a part of a medical record? Doctor's credentials Demographic data Insurance information Correspondence

Doctor's credentials

A patient, Patrick, claims that he received a treatment from Westerville Medical Center last month. However, the treatment is not recorded in his medical record. Which of the following is true according to the law? The patient is always right. The treatment did not occur. The patient is a liar and may be prosecuted. The medical record must be updated immediately.

The treatment did not occur.

One of the primary uses of medical records is to evidence patterns in a patient's condition.

True

What should be at the front of a problem-oriented medical record? Demographic information Insurance information An information sheet A signed release form

An information sheet

Which of the following is NOT a feature of most EMRs? Immediate access to patient records Filing of physical folders Record medications and send information to the pharmacy Create and print customized forms

Filing of physical folders

Which of the following laws provides guidelines for using electronic medical records?

HIPAA Security Rule

Which of the following is the best description of a problem-oriented medical record? Items of the same insurance carrier are filed together. Items of the same source are filed together. Items of the same severity are filed together. Items of the same medical condition are filed together.

Items of the same medical condition are filed together.

Which of the following is an advantage of using paper medical records? They require a lot of storage space. They are easily misplaced. They are complicated and hard to understand. They are easy to keep confidential.

They are easy to keep confidential.

What must be true of all electronic medical records?

They must be password protected

Which of the following is true about medical records?

They provide a written account of a patient's health care.

A benefit of using source-oriented medical records is that specific items can be found quickly.

True

EMR programs can store more information without running out of storage space.

True