Medical Transcription - Chapter 1 Review Test

Who owns the patient's medical records?

Physician, corporation, or institution

Your aunt is visiting and complains to you that she cannot get her physician to return her phone calls and she desperately wants to know if her recent biopsy finding is positive or negative. What would you do?

Tell her to relax and find out what is going on with the doctor

If your state has laws protecting patient confidentiality that are stricter than the federal guidelines, to which do you conform?

The State

What, if any, is the value of becoming a CMT (certified medical transcriptionist) or RMT (registered medical transcriptionist)?

To be recognize as a profession

One would not consider it a breach of HIPAA if you completed your medical transcription from your home. T___F___

True

When may you disclose protected health information?

Written consent from the patient

State at least four skills that a successful transcriptionist should have:

a. Has excellent word processing b. Has knowledge of medical transcription guidelines and practices c. Has excellent spelling, editing, and proofreading d. Has a good command English grammar

Briefly list three main purposes of medical records:

a. Help physician in the treatment of patient and future research b. Practice legal standards c. Follow the joint commission

Name two classifications of information contained in medical records:

a. Name and address of person b. Social security

When you have successfully delivered your transcript, your downloaded files and paper files should be a. Kept indefinitely b. Shredded or purged from your equipment c. Converted into an electronic file d. Mailed to a secure repository

c. Converted into an electronic file

If a surgeon dictates the operative report before the time of surgery, it is: a. None of the transcriptionist's business b. A matter for utilization review c. Discussed with risk management d. Pointed out to the surgeon

c. Discussed with risk management

Where are electronic medical records stored? a. In the transcriptionist's computer b. In the dictator's computer c. On the Internet d. In the computer where they were downloaded e. None of the above

c. On the Internet

What does the reimbursement chain refer to? a. The fact that documents you transcribe generate revenue. b. Your payment for transcription based on lines transcribed or the visible black character (VBC). c. The encryption of the medical record for billing. d. A report being returned for authentication.

d. A report being returned for authentication.

Turn-around-time (TAT) concerns a. Your billing for the transcript b. Security of the medical record c. Conforming to HIPAA regulations. d. Joint Commission regulations

d. Joint Commission regulations

In which of the following instances can the medical records of a patient be released to a third party without the patient's written permission? a. Under no circumstances b. With a subpoena duces tecum c. Upon request of the police or prison officials d. On the hospital administrator's authority only

d. On the hospital administrator's authority only

In transcribing, what is even more important that speed?

Accuracy

Name one main difference between a job and a career.

A job is a stepping stone to a lifelong career

What is the main hazard in using the Internet for research?

Be careful to use accurate and valid websites for research

There is an "unwritten rule" in medicine that if you did not document it

Did not happen

Is the risk manager responsible for patients, visitors, or employees of a facility?

Employees

If you work as an "independent" contractor doing medical transcription, you become exempt from the HIPAA privacy restrictions. T___F___

False

Name the federal entity that provides specific guidelines for patient privacy:

HIPAA (Health Insurance Portability & Accountability Act)

How would you alert the document author if you found a critical error or discrepancy in a dictation?

Let that person know and find out why they are wrong

According to the standards of Joint Commission, what is the deadline for completion of a physical examination report on an inpatient?

24 hours

Written or typed information set down for the purpose of preserving memory that authenticates evidence of facts and events is a/an:

Medical Records