Deck 14: The Paper Medical Record Formerly Medical Records Management

Question 1

An aggregate of activities designed to ensure adequate quality is called quality control.

Answer 1

True

Question 2

When documents are added to a patient's chart, the most recent information should be placed on top.

Answer 2

True

Question 3

The computer-based medical record has no disadvantages, whereas the paper-based record has numerous disadvantages.

Answer 3

False

Question 4

Whatever medical records system is used in a facility, it should first provide for easy retrieval of records, and it must work for the individual facility.

Question 5

By legal definition, if it isn't charted, then it didn't happen.

Question 6

All physicians currently use electronic health records.

Question 7

Numeric filing is a direct filing system.

Question 8

Color coding is used only for patients' records and not for business records.

Question 9

The patient's medical record should never leave the office.

Question 10

Subjective information is that which the physician observes during the physical examination of the patient.

Question 11

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

Question 12

Only the physician owns the medical record.

Question 13

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

A)Source oriented
B)Problem oriented
C)Progressively
D)Chronologically

Question 14

Medical records offer protection to the physician during legal proceedings if they are accurate and complete.

Question 15

Numeric filing provides extra confidentiality to medical records.

Question 16

The three basic filing methods are alphabetic, numeric, and alphanumeric.

Question 17

The patient owns the medical record.

Question 18

Conditioning papers involves including a mark that indicates the papers are ready for filing.

Question 19

It is not necessary to keep a copy of a patient's consent form in the chart.

Question 20

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

Question 21

The medical record should be released only with a:

A)verbal order from the physician
B)written order from the physician
C)written release from the patient
D)verbal order from the office manager

Question 22

Which statement is not accurate about correcting charting errors?

A)Insert the correction above or immediately after the error.
B)Draw two clear lines through the error.
C)In the margin, initial and date the error correction.
D)Do not hide charting errors.

Question 23

Who is the legal owner of the information stored in a patient's record?

A)The patient
B)The physician or agency where services were provided
C)The patient's insurance company
D)Both the patient and the physician

Question 24

Continuity of care means :

A)an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries
B)a formal examination of an organization's or individual's accounts
C)medical attention that continues smoothly from one provider to another so that the patient receives the most benefit
D)granted or endowed with a particular authority

Question 25

Which of the following is not an advantage of color-coded filing systems?

A)Patient charts can be found quickly.
B)It is easy to tell when a file has been misplaced.
C)Patient charts can be refiled quickly.
D)All of the above are advantages.

Question 26

How would you properly index the name "Amanda M.Stiles-Duncan" for filing?

A)Stilesduncan, Amanda M.
B)Stiles Duncan, Amanda M.
C)Duncanstiles, Amanda M.
D)Duncan, Amanda M.Stiles

Question 27

A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files is called a(n) _____________ system.

A)shelf filing
B)indirect filing
C)direct filing
D)shingling

Question 28

Which of the following are not needed when describing a patient's chief complaint?

A)Remedies the patient has tried to relieve symptoms
B)The duration of pain
C)The time when symptoms were first noticed
D)How many family members are healthy

Question 29

A legal instrument that authorizes a person to act as the agent of the grantor is called a:

A)power of attorney
B)will
C)medical record release
D)requisite

Question 30

Information that is gained by questioning the patient or that is taken from a form is called ________________ information.

A)confidential
B)subjective
C)objective
D)necessary

Question 31

Which of the following steps for records release is out of order?

A)Explain to the patient that the release form is necessary.
B)Have the patient sign the form in the space indicated.
C)Review the record release form with the patient and ask whether the person understands it.
D)Make a copy of the form for the patient's chart.

Question 32

Medical facilities should keep records on minors for how long?

A)Indefinitely
B)Until the minor is deceased
C)For 10 years
D)Until the minor reaches the age of majority, plus 3 years

Question 33

Which of the following are common types of filing equipment found in a medical office?

A)Rotary circular files
B)Lateral files
C)Automated files
D)All of the above

Question 34

An informed consent form must address which of the following?

A)Risks and benefits of the procedure
B)Reasonable alternatives to the procedure
C)Risks and benefits of not performing the procedure
D)All of the above

Question 35

Which of the following is not an advantage of a numeric filing system?

A)It allows periodic expansion without shifting folders.
B)It provides additional confidentiality to the chart.
C)Filing activity is greatest when the system is initiated.
D)It saves time in record retrieval and refiling.

Question 36

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?

A)Dr.Jill Freeman
B)Freeman, Dr.Jill
C)Freeman, Jill
D)Freeman, Jill M.D.

Question 37

What is the most important reason for telling the physician when a charting error is discovered later?

A)To protect the patient's health and well-being
B)To protect the medical assistant's job
C)To make sure the medical assistant is not accused of making the error
D)To keep the patient from discovering the error

Question 38

Releasing a record, with regard to filing it, means :

A)removing pins and paper clips
B)deciding where to file a particular item
C)placing a mark indicating that the item is ready for filing
D)arranging papers in filing sequence

Question 39

Which of the following is not objective information?

A)Progress notes
B)Family history
C)Diagnosis
D)Physical examination and findings

Question 40

Which statement is not true regarding the reasons for keeping accurate medical records?

A)The medical record provides critical information for other caregivers.
B)Effects of various treatments can be tracked and statistics gleaned from them.
C)The patient's family may want to examine the records and correct errors.
D)Accurate records are vital for financial reimbursements.

Question 41

Who ultimately decides whether a medical record can be released?

A)The physician
B)The office manager
C)The medical assistant
D)The patient

Question 42

The medical assistant should consider which of the following when selecting filing equipment?

A)Fire protection
B)Cost of space and equipment
C)Confidentiality requirements
D)All of the above

Question 43

A correction to a medical record can be made by:

A)drawing a line through the entry and writing the correct information
B)whiting out the entry and writing over it
C)rewriting the entire page of progress notes with the error corrected
D)any of the these methods

Question 44

The newest component used today to complete transcription and authenticate records is __________ software.

A)voice-activated
B)voice recognition
C)voice registry
D)voice-controlled

Question 45

An item used to provide space for the temporary filing of materials is called a(n):

A)OUTguide
B)OUTfolder
C)shingle
D)caption

Question 46

A temporary or transitory file might be used for a:

A)patient from another area who is only in the city for a short while
B)letter requesting a reprint from a magazine
C)letter requesting information about a product or drug
D)all of the above

Question 47

HIPAA recommends that physicians keep the records on patients for at least:

A)1 year
B)2 years
C)3 years
D)HIPAA does not recommend a number of years.

Question 48

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

A)rationale
B)response
C)repeat
D)reinforce

Question 49

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

A)entry
B)evaluation
C)education
D)exclude

Question 50

The physical medical record belongs to the:

A)patient
B)physician or provider
C)insurance company
D)all of the above

Question 51

The most efficient type of medical record is the:

A)computer-based medical record
B)paper-based medical record
C)both are equally efficient
D)neither is efficient

Question 52

Which of the following names should be filed first?

A)A.Martin
B)Amy Martin

Question 53

A strong, highly glazed composition paper or heavy card stock is called:

A)augment
B)pressboard
C)microfilm
D)shingle

Question 54

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

A)inactive
B)closed
C)active
D)dead

Question 55

The three stages of machine transcription do not include:

A)keyboarding the dictated text to a printed document
B)reviewing the dictated text with the patient
C)dictating into a dictation unit
D)listening to what has been dictated

Question 56

The method of filing in which one report is laid on top of the older report, resembling a roof, is called:

A)alphanumeric filing
B)gleaning
C)shingling
D)pressboard filing

Question 57

The preferred filing method for a physician's office is:

A)alphabetic
B)numeric
C)alphanumeric
D)the one most preferred by the staff

Question 58

Transcription tasks might be outsourced to:

A)individuals working at home
B)a business that offers transcription services
C)a hospital employee who does extra transcription work
D)any of the above

Question 59

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

A)purging
B)indexing
C)coding
D)conditioning

Question 60

When preparing a file for a new patient, the medical assistant should:

A)make sure the patient's name is spelled correctly
B)review the forms the patient filled out for completeness
C)copy the insurance card or make sure that insurance information is included
D)all of the above

Question 61

Which of the following names should be filed first?

A)A Roberts Production
B)The Robertson Clinic

Question 62

Computer-based medical records are sometimes called __________ health records.

Question 63

Information picked up bit by bit is said to be __________.

Question 64

A(n) __________ is made of heavy paper stock and is used to replace an entire folder that has been temporarily removed from its proper place.

Question 65

A power of __________ allows one person to act on behalf of another.

Question 66

To be granted or endowed with a particular authority or right is to be __________.

Question 67

Which of the following names should be filed first?

A)Wm.Jones
B)William Jones

Question 68

A folder used to provide space for the temporary filing of materials is a(n) __________.

Question 69

Which of the following names should be filed first?

A)MacAllister
B)McAllister

Question 70

__________ information is provided by the patient.

Question 71

Deciding where to file a particular chart based on the patient's name is called __________.

Question 72

A(n) __________ file is a follow-up system used to help the medical assistant remember when a certain task needs to be done.

Question 73

The concise account of the patient's symptoms in his or her own words is the __________.

Question 74

To make greater, more numerous, larger, or more intense is to __________.

Question 75

When a patient is transferred from one facility to another, __________ of care ensures that no lapses in treatment occur and that transitions are smooth.

Question 76

The __________ diagnosis is temporary and is made before test results have been received.

Question 77

A filing system that uses a combination of letters and numbers is said to be __________.

Question 78

__________ information is observed by the physician.

Question 79

__________ of an entry in a medical record is never acceptable.

Question 80

Which is the correct way to designate this patient's name in filing?

A)Doe, Mary Jones (Mrs.John L.)
B)Doe, Mrs.John L.(Mary)