Deck 8: Patient Clinical Records

Question 1

Which of the following is the recommended spacing between progress note entries?

A)There should be no space between progress note entries.
B)Spacing between entries should be limited to one or two lines.
C)Spacing between progress note entries should be limited to three lines.
D)Ample spacing of approximately four lines should be left between progress note entries,to accommodate amendments to the original entry.

Answer 1

Spacing between entries should be limited to one or two lines.

Question 2

The component of the patient clinical record that is considered "a necessary form" is the:

A)correspondence log.
B)signature on the file form.
C)registration form.
D)treatment plan form.

Answer 2

registration form.

Question 3

The primary reason for carefully maintaining clinical records is to:

A)Support the need for dental treatment
B)Justify the actions of the dentist
C)Provide information for forensic odontology
D)Both A and B

Answer 3

Both A and B

Question 4

Patients should be able to see the information in their clinical record.HIPAA regulations state that the office should provide access to the records or should provide a copy within 30 days of a written request.This is known as:

A)Limits on Use of Personal Medical and Dental Information.
B)Confidential Communications.
C)Access to Clinical Records.
D)Protected Health Information.

Question 5

The _______ is a communications system designed to transmit patient health information;when fully developed,it will allow individuals to create and control a personal health record.

A)The National Security Standards Program
B)The National Health Information Infrastructure
C)The National Confidential Communications Structure
D)The National Patient Correspondence Log

Question 6

Administrative safeguards that apply to electronic clinical records include identification of who will supervise compliance with HIPAA Security Standards,a staff clearance procedure that identifies which members of the staff will have access to electronic protected health information (EPHI),and:

A)a disaster recovery plan.
B)access control,which includes unique user identification (password and biometric systems).
C)retention of off-site computer backups.
D)protection of electronic systems,equipment,and data that contain EPHI from environmental hazards and unauthorized intrusion.

Question 7

Which of the following is NOT an advantage of computer-generated clinical records?

A)The dental practice will not need to employ an administrative assistant.
B)Entries are automatically signed with the code of the person making the entry.
C)All needed information must be entered before the program can be closed.
D)Computer-generated progress notes are more easily read than handwritten entries.

Question 8

Without a patient's written authorization,personal health information (PHI)cannot be shared with others for purposes unrelated to their healthcare.However,the Privacy Rule (HIPAA)mandates the disclosure of limited health information to satisfy specific public responsibilities.

A)The first statement is true;the second statement is false.
B)The first statement is false;the second statement is true.
C)Both statements are true.
D)Both statements are false.

Question 9

Why is it important to document missed and broken appointments in the clinical record?

A)So patients can be billed if they failed to give timely notice
B)So a follow-up letter can be sent to explain the importance of continued treatment
C)To document the intent of the dentist to complete work and follow-up in a timely manner
D)To document that postoperative instructions are not being followed

Question 10

Which of the following describes the Equivalent Requirements for Government?

A)State that the provisions of the Privacy Rule generally apply equally to private sector- and public sector-covered entities
B)Indicate that law enforcement activities are limited
C)Are concerned that oversight of the healthcare system is provided
D)Ensure that judicial and administrative proceedings are completed

Question 11

Diagnostic models are:

A)stored in the patient clinical record.
B)used to provide patient teaching.
C)casts of the patient's mouth.
D)used for practice in a dental assisting class.

Question 12

What is the most important reason why complete medical history is taken before dental treatment is provided?

A)It should not be taken because it violates the patient's confidentiality.
B)So the dentist will be aware of any medication the patient is taking
C)Because the patient's medical doctors are reluctant to release information to a dental office
D)Careful review of medical history will alert the dentist to possible interactions between dental and medical treatment.

Question 13

If a mistake is made in the clinical record,what procedure should be followed to make the correction?

A)Replace the form and rewrite the information.
B)Use "white-out" to cover the error,and rewrite the information over it.
C)Cross it out so it is illegible,and write the error.
D)Cross out the error with a single line,date and initial the error,and then write the correction information.

Question 14

The clinical record process starts and ends with the _______,who plays a key role in protecting the dental practice from malpractice litigation.

A)administrative assistant
B)dentist
C)hygienist
D)expanded function assistant

Question 15

Which of the following is not included in the written privacy procedures?

A)Which members of the staff will have access to private health information
B)How private health information will be used
C)Where off-site computer backups are located
D)When private health information may be disclosed

Question 16

Which of the following forms provides the dental practice with the patient's demographic and financial information?

A)The patient registration form
B)The comprehensive medical history
C)The dental history
D)The treatment plan

Question 17

New patients should be instructed to arrive _______ early to complete paperwork if they are unable to complete the registration and medical history forms before arriving for their first appointment.

A)5 minutes
B)15 minutes
C)30 minutes
D)60 minutes

Question 18

The key elements of record keeping include organization,completeness,and:

A)accuracy.
B)consistency.
C)neatness.
D)accessibility.

Question 19

What is the primary function of the clinical record?

A)To provide a dental history for the patient
B)To provide identification of the patient
C)To document dental treatment
D)To provide a total picture of the patient and the patient's needs

Question 21

Of the following diagnostic tools,which is used to photograph teeth and their surrounding tissue?

A)Digital radiograph imaging system
B)Periodontal evaluation procedure
C)Intraoral study model technique
D)Intraoral imaging system

Question 22

Noncompliance with statutes and regulations established by federal law can result in the dentist losing his/her dental license.

Question 23

The clinical chart notation NSF is an abbreviation for ______.

Question 24

The dental healthcare team can lessen the likelihood of a malpractice suit through _______,a process of identifying procedures that are not in compliance with mandated regulations.

A)treatment planning
B)cross-referencing
C)risk management
D)hazard assessment