Deck 5: Managing Health Information

Question 1

Another name for a central computer is:

A) Network
B) File server
C) Hard drive
D) Program

Answer 1

File server

Question 2

Online medical _____ are used to educate physicians concerning conditions and treatment regimes.

A) Games
B) Companions
C) Databases
D) Courses

Answer 2

Databases

Question 3

Most medical billing offices use an electronic medical billing program. Which of these is one example of such a program?

A) Medicare
B) Medisoft
C) Medidata
D) Medical Manager

Answer 3

Medisoft

Question 4

Accurate financial records are required for _____ and are critical for the practice's success.

A) Billing
B) Purchasing
C) Tax reporting
D) Employee payroll

Question 5

One of the most important tasks of an administrative medical assistant is the creation of:

A) Patient data
B) Patient accounts
C) Practice documents
D) Health insurance claims

Question 6

_____ computers are the most powerful computers available.

A) Mini
B) Super
C) Mainframe
D) Personal

Question 7

_____ computers are used in large businesses, hospitals, large clinics, and government organizations.

A) Mainframe
B) Mini
C) Super
D) Personal

Question 8

_____ computers have less power than mainframes.

A) Hospital
B) Super
C) Giant
D) Mini

Question 9

To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between ________ away.

A) 1 and 1.5 feet
B) 2 and 2.5 feet
C) 3 and 3.5 feet
D) 4 and 5.5 feet

Question 10

A(n) _____ is a standard version of a document that is used over and over again.

A) Template
B) Form
C) Stencil
D) Sample

Question 11

What can be assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail?

A) Locks
B) Log-ons
C) Permissions
D) Passwords

Question 12

A patient's medical record constitutes the _____ record of the medical practice.

A) Established
B) Official
C) Legal
D) Valid

Question 13

Making corrections to a chart with an eraser or scribbling out entries could present the appearance of _______________.

A) A mistake
B) Carelessness
C) Fraud
D) Cheating

Question 14

If you make an error while recording an entry in the medical record, do all of the following except

A) Write the word "error" next to the error.
B) Write your initials next to error.
C) Use correction tape to keep the entry neat.
D) Write the date next to the error.

Question 15

Offices using electronic medical record entry methods should affix what to all chart entries?

A) A label
B) A validation code
C) An electronic date stamp
D) An electronic signature

Question 16

A chronological record of ongoing patient care and progress is also known as

A) A chart note.
B) A chart plan.
C) A legal note.
D) A patient plan.

Question 17

What method is the most common system for outlining and structuring chart notes for a medical record?

A) CHEDDAR
B) SOAP
C) POMR
D) SOMR

Question 18

Which charting format breaks down the components of a patient encounter into seven detail-oriented sections?

A) CHEDDAR
B) SOAP
C) POMR
D) SOMR

Question 19

The _____ findings in a SOAP record are the physician's examination of the patient.

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 20

The _____ findings in a SOAP record are the patient's description of the problem or the complaint.

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 21

Based on the Master Problem List and the initial problems of the patient, the physician

A) Makes a diagnosis.
B) Makes a prognosis.
C) Begins a course of treatment.
D) Defines an outcome.

Question 22

All medical records should be kept until:

A) The physician retires
B) The practice closes
C) The patient dies
D) The possibility of a malpractice suit has passed

Question 23

When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be:

A) Active
B) Closed
C) Inactive
D) Retired

Question 24

What is the best measurement of the quality of care given to a patient?

A) The medical record
B) Patient compliance
C) The physician's reputation
D) Patient cure rate

Question 25

Patients ____ the right to inspect their medical documentation.

A) have
B) do not have
C) must earn
D) may sue the physician for

Question 26

Which type of file pertains to current patients?

A) Inactive
B) Active
C) Closed
D) Closed storage

Question 27

Which type of file relates to patients who have not seen the physician for six months?

A) Active
B) Inactive
C) Closed
D) Closed storage

Question 28

Federal law _____ regulate retention time frames for patient's medical records.

A) Does
B) Does not
C) May opt to
D) Can, in some cases

Question 29

All ____ records must be kept according to the same retention schedule as that for older paper records.

A) Physician
B) Photocopied
C) Inactive or closed
D) Electronically stored

Question 30

Records that have been closed and those that must be kept permanently are said to be in _____ storage, a storage area separate from the area where active files are kept.

A) Secure
B) Active
C) Safe
D) Dead

Question 31

Dead storage ________ be easily accessible.

A) Needs to
B) Need not
C) Can
D) Will never

Question 32

In the medical office, how many main types of records are there?

A) One
B) Two
C) Three
D) Four

Question 33

The central responsibility of the physician's practice is:

A) Patient reviews
B) Patient care
C) Preventative visits
D) Patient payment

Question 34

Which type of files are kept in one place?

A) Decentralized
B) Centralized
C) Dead
D) Open-shelf files

Question 35

Information of use to only one staff member, such as a physician's correspondence, is stored in a _____ file convenient to the user.

A) Decentralized
B) Centralized
C) Dead
D) Open-shelf

Question 36

The need to conserve space in many offices has made _____ files popular.

A) Centralized
B) Dead
C) Decentralized
D) Open-shelf

Question 37

Which type of files save time and labor but may sacrifice some security?

A) Open-shelf files
B) Decentralized files
C) Dead files
D) Centralized files

Question 38

Which type of files are arranged from front to back?

A) Open-shelf files
B) Centralized files
C) Vertical files
D) Centralized files and vertical files

Question 39

Which type of files are arranged from left to right, instead of from front to back?

A) Open-shelf files
B) Centralized files
C) Vertical files
D) Lateral files

Question 40

File folders may be open on how many sides?

A) One and two only
B) Two and three only
C) One and three only
D) One, two, or three

Question 41

How many steps are included in filing?

A) Five
B) Four
C) Three
D) Two

Question 42

_____ is the mental process of selecting the name, title, or classification under which an item will be filed.

A) Sorting
B) Storing
C) Coding
D) Indexing

Question 43

_____ is the placing of a number, a letter, or an underscore beneath a word to indicate where the document should be filed.

A) Coding
B) Indexing
C) Sorting
D) Storing

Question 44

What type of file should be consulted daily?

A) Centralized
B) Tickler
C) Decentralized
D) Cross-reference

Question 45

How many rules are there for alphabetic filing?

A) Four
B) Six
C) Eight
D) Ten

Question 46

It is currently estimated that _____ percent of healthcare facilities and _____ percent of physician practices have already implemented EHRs.

A) 60; 40
B) 70; 30
C) 80; 50
D) 90; 60

Question 47

More than one person ________ use stored data at the same time.

A) can
B) cannot
C) must
D) must not

Question 48

Policies and procedures for updating medical personnel and evidence of the training should be placed in the _____.

A) Compliance manual
B) Personnel manual
C) Procedure manual
D) Rule manual

Question 49

Until electronic health records are fully implemented into the healthcare system, _____ will be needed.

A) Fax machines
B) Temporary personnel
C) File clerks
D) Scanners

Question 50

Completely removing electronic data could give the appearance of _____ and is not permissible in many programs.

A) Cheating
B) Liability
C) Fraud
D) Carelessness

Question 51

_____ in medical documentation can lead to a vast array of consequences.

A) Information
B) Mistakes
C) Punctuation
D) Abbreviations

Question 52

Transcriptionists often use _____ to input medical data.

A) Keyboards
B) Templates
C) Pencils
D) Pens

Question 53

Lydia works exclusively inputting data into medical records. She seldom takes a break from inputting and works 4 days per week, 10 hours each day. While driving, she notices a change in her distance vision. Which of the following should she do to help ease eye strain while working?

A) Place her hands and wrists in horizontal alignment.
B) Regularly focus on distant objects.
C) Place source documents flat beside her computer.
D) Frequently rotate her neck and shoulders.

Question 54

Shannon works for a medical practice that uses the first three letters of the patient's last name and the date of birth as the patient numbers. When Shannon was filing medical insurance claims, she noticed that a chart note had been made in the wrong chart. The physician sees twin females, and the chart for the wrong twin had been noted. To correct the error, Shannon should:

A) Eliminate the chart note with correction fluid.
B) Use a wide, permanent black marker to cross out the chart note.
C) Place a straight line through the entry, making sure it is still legible; mark it "error" date her correction; and initial the correction.
D) Place a wavy line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction.

Question 55

Which of the following is an acceptable chart notation for "as needed"?

A) q.4.h
B) p.r.n.
C) a.n.
D) as ndd

Question 56

Entries should be signed and __________.

A) Time stamped only
B) Date stamped only
C) Both signed and date stamped
D) Verified

Question 57

Excel is an example of what type of software?

A) Database management software
B) Graphics application
C) Word processing program
D) Spreadsheet program

Question 58

Which of these is used to enter, edit, format, and print documents?

A) Computer network
B) Template
C) Word processing program
D) File server

Question 59

Electronic maintenance of the medical office schedule provides _______________ over paper appointment books.

A) Advantages
B) Disadvantages
C) Difficulties
D) Inconveniences

Question 60

After a patient encounter, the new electronic medical data should be reviewed and __________ for errors.

A) Proofread
B) Verified
C) Transferred
D) Templated

Question 61

Laws have been passed and large sums of money have been, and are being, invested in the implementation of what?

A) Electronic signatures
B) Hospital documentation
C) Office check in/out policies
D) Healthcare reform

Question 62

Using the ______ system, it is easy to locate misfiled charts with a quick glance.

A) Subject filing
B) Color coding
C) Numeric coding
D) Indirect filing

Question 63

An accession book is used with which type of filing?

A) Subject filing book
B) Alphabetic filing
C) Numeric filing
D) Compliance filing

Question 64

A technology being used in medical and other offices for data input is ____________.

A) Voice recognition technology
B) Transcription
C) Voice conferencing
D) Fax machine

Question 65

Which newer form of communication uses radio waves, rather than wires or cables?

A) Dial-up communication
B) Computer network communication
C) Wireless communication
D) Supercomputer communication

Question 66

_______________________, or AUP, should be written and included in the office's policy and procedure manual.

A) Acceptable use policies
B) Administrative use policies
C) Acceptable user profiles
D) Administrative user profiles

Question 67

Which of these includes word processing, graphics, spreadsheet, and database management applications?

A) Operating system
B) Application software
C) Computer mainframe
D) Screen savers

Question 68

The CC is located where in the SOAP note?

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 69

What are the three essential components of POMR?

A) SOAP, CHEDDAR, Master Problem List
B) CHEDDAR, Master Problem List, Initial Plan
C) Master Problem List, CC, Initial Plan
D) Database, Master Problem List, Initial Plan