Deck 9: The Medical Record

Question 1

Computerized medical records

A)pose problems of confidentiality.
B)make record maintenance and retrieval more efficient.
C)should be accessed on a need-to-know basis.
D)all of the above.

Answer 1

all of the above.

Question 2

Patient information in the medical record should include

A)the date of birth.
B)the date of marriage.
C)a record of divorces.
D)the date of the spouse's birth.

Answer 2

the date of birth.

Question 3

The purpose of a medical record is to

A)provide the billing record of the patient from admission to the practice.
B)provide the medical picture and record of the patient from birth to death.
C)provide data and statistics on health matters.
D)B and C.

Answer 3

B and C.

Question 4

Physicians who wish to disclose confidential medical record information should

A)first discuss it with the patient's family.
B)discuss it with the patient first.
C)discuss the risks involved with his or her lawyer.
D)first discuss the problem with the patient's contact person.

Question 5

When preparing a copy of a medical record for a third party,

A)keep the copy and send the original.
B)make two copies and send the original.
C)keep the original and send a copy.
D)make a copy of the complete record and send it even when one part is requested.

Question 6

An incomplete medical record may

A)not be a problem,as the remainder of the entry could be discussed during a court hearing.
B)make it impossible for the healthcare provider to defend allegations in court.
C)allow only part of a bill to be paid.
D)not be able to be subpoenaed to court.

Question 7

Ownership of the medical record usually remains with the

A)physician.
B)patient.
C)court.
D)all of the above.

Question 8

The medical record must include information about patient care such as

A)admitting diagnosis.
B)physician examination report and documentation of complications.
C)discharge summary and follow-up care.
D)all of the above.

Question 9

The accepted method of correcting medical record errors is

A)erase and write the correction.
B)draw a line through the error and write the correction underneath.
C)draw a line through the error and write the correction above with the date and initials of the person making the correction.
D)erase and write the correction,adding the date and initials of the person making the correction.

Question 10

A medical record ordered by the court to be available during a malpractice case is

A)disclosed.
B)subpoenaed.
C)disclosed only to the judge.
D)disclosed only to the jury.

Question 11

The disadvantage of chronological documentation is

A)subjective data may be missing.
B)objective data may be missing.
C)medical problems may go undiscovered.
D)vital signs are not done.

Question 12

For the court's purpose,if documentation does not appear in the medical record

A)it did not occur.
B)it can be documented at a later date without harm.
C)the court will not use the medical record against the healthcare provider.
D)all of the above.

Question 13

All medical records should be stored for

A)5 years from the date of the last entry.
B)7 years from the date of the last entry.
C)10 years from the date of the last entry.
D)23 years from the date of the last entry.

Question 14

The Privacy Act of 1974 protects private citizens from distribution of information about themselves by the federal government except for that which is received from

A)hospitals.
B)Veterans Administration hospitals.
C)privately owned clinics.
D)Medicare or Medicaid.

Question 15

Confidential medical record information that can be disclosed to a health department without the patient's consent includes

A)HIV cases.
B)AIDS cases.
C)abortions.
D)A and B.

Question 16

Medical record management requires

A)accuracy.
B)confidentiality.
C)proper filing and storage.
D)all of the above.

Question 17

Older records of former patients

A)need to be kept in the physician's office indefinitely.
B)can be stored in a clean,dry storage space.
C)can be destroyed after 5 years.
D)need to be kept in the physician's office for at least 7 years.

Question 18

Federal reimbursement guidelines require that all medical records be completed within

A)15 days following the patient's discharge from a hospital.
B)30 days following the patient's discharge from a hospital.
C)45 days following the patient's discharge from a hospital.
D)60 days following the patient's discharge from a hospital.

Question 19

To protect patient confidentiality,medical records can be released

A)to an attorney.
B)to a judge.
C)to the patient's family members.
D)only with the patient's written consent.

Question 20

Medical records are usually exempt from state open-record laws except when

A)the benefit of disclosure for the public interest (safety)outweighs confidentiality.
B)requested by a family member to be disclosed to the public.
C)mental health records are to be disclosed to the public.
D)an attorney requests the records to be made public.

Question 21

Immunization records should be kept

A)for 10 years.
B)permanently.
C)for 5 years.
D)until the age of maturity.

Question 22

A subpoenaed medical record should alert the medical staff that

A)the physician and the patient are to be told that a subpoena has been served.
B)the physician's attorney should be notified of the subpoena being received.
C)the records must be turned over to the judge on the specified date.
D)all of the above.

Question 23

Laws regarding medical records

A)are mandated by the federal government.
B)apply to individual healthcare facilities.
C)vary from state to state.
D)are the same from state to state.

Question 24

A written order requiring a person to appear in court,give testimony,and bring the records described is called

A)res ipsa loquitur.
B)subpoena duces tecum.
C)respondeat superior.
D)a subpoena.

Question 25

Healthcare providers and healthcare institutions who disclose confidential health information may

A)do so without consequences.
B)face civil or criminal liability for disclosure.
C)face civil liability for disclosure.
D)face criminal liability for disclosure.