chapter 10

The source-oriented medical record (SOMR) categorizes the content by its source, such as provider, laboratory, radiology, hospital, and consultation.The problem-oriented medical record (POMR) categorizes each of the patient's problems and elaborates on the findings and treatment plans for all concerns

both statements are correct

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.

The patient owns the medical record.

false

PHI stands for "private health information."

false, the p stands for PROTECTED

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.

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

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

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.

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

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

closed

The "E" entry in the SOAPER charting method means:

education

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

false

Charge capture relates to charges for missed appointments.

false

A filing system in which an alphabetic cross-reference must be consulted to locate specific files is called a(n) _____________ system.

indirect filing

Continuity of care means:

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

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

progressively

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

purging

Who ultimately decides whether a medical record can be released?

the patient

The most frequently used follow-up method is a:

tickler file

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

true

The medical record should be released only with a:

written release from the patient