Deck 13: The Skeletal System

Question 1

The ____ is generally the first person to inspect reports.

A) patient
B) insurance company
C) medical assistant
D) provider

Answer 1

medical assistant

Question 2

When filing records in a new file cabinet, it is recommended that you:

A) space out files evenly in all drawers
B) place files in the middle drawers first
C) place files in the top drawer first
D) place files in the bottom drawers first

Answer 2

place files in the bottom drawers first

Question 3

What does the P in SOAP stand for?

A) physician, provider, or medical practice
B) patient
C) plans for further studies, treatment, or management
D) preventive care

Answer 3

plans for further studies, treatment, or management

Question 4

What does the I in the HPIP method stand for?

A) investigate
B) impression
C) insurance
D) intestinal

Question 5

In regard to filing, _____ is done by marking the index identifier on the paper to be filed.

A) indexing
B) sorting
C) storing
D) coding

Question 6

When recording progress notes, the specific chief complaint should be:

A) a paraphrased description of the patient's condition
B) written using the patient's own words
C) a series of codes that correlate to a list of common symptoms
D) recorded only by the physician or provider

Question 7

A HIPAA Security Rule audit includes a review of all but which of the following categories?

A) drug authorizations
B) organizational requirements
C) documentation
D) administrative safeguards

Question 8

The patient chart belongs to the:

A) patient
B) patient's insurance company
C) medical practice
D) person who prepared it

Question 9

The primary benefit of a(n) _____ filing system is that it distributes files evenly over given spaces.

A) chronologic
B) alphabetic
C) numeric
D) geographic

Question 10

Which of the following are simply a collection of medical records compiled and maintained by an individual?

A) electronic medical records (EMRs)
B) personal electronic records (PERs)
C) electronic health records (EHRs)
D) personal health records (PHRs)

Question 11

Most filing systems are based directly or indirectly on a(n) _____ arrangement.

A) chronologic
B) alphabetical
C) geographic
D) subject

Question 12

What do the two Ds in CHEDDAR stand for?

A) details and drugs
B) dosages and drugs
C) details and documentation
D) dosages and documentation

Question 13

A complete and accurate medical record provides legal protection for:

A) patients
B) physicians
C) both patients and physicians
D) neither patients nor physicians

Question 14

Lab reports should be filed in _____ in a separate section of the patient chart.

A) alphabetical order
B) order of relevance
C) chronological order
D) order of importance

Question 15

The primary disadvantage of the _____ filing system is that it requires a degree of familiarity of a certain area.

A) geographic
B) subject
C) alphabetical
D) chronologic

Question 16

Which of the following is an objective statement?

A) You don't look well.
B) Mrs. Smith says her mouth feels dry.
C) I have a headache.
D) The patient's heart rate is elevated at 120 beats per minute.

Question 17

It is recommended that filing dividers or guides be constructed of _____ material.

A) heavy, sturdy
B) light, flexible
C) transparent, flexible
D) sturdy, magnetic

Question 18

When the patient's paper chart is opened flat, which of the following is typically found on the right side?

A) progress notes
B) medication list
C) patient data
D) immunization records

Question 19

When using the POMR method of record keeping, which of the following types of information appear on the same page?

A) medication lists and preventive care lists
B) the chief complaint and list chronic problems
C) education information provided to the patient, and the review of systems
D) the patient profile and list of chronic problems

Question 20

Which of the following is not an advantage of EHRs?

A) They facilitate coordination of care among providers.
B) They completely eliminate the necessity for paper records.
C) They can assign CPT and ICD codes at the time of the visit.
D) They make chart notes immediately available when a referral is needed.

Question 21

Match each term with its definition.
These typically bear a disclaimer that states the report has or has not been reviewed for accuracy

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 22

Match each example of information to the part of the medical record in which it would be found.
Preliminary report of a patient's test results

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 23

Match each term with its definition.
This term once referred only to Roentgen films, but today also includes ultrasounds, angiograms, MRIs, and other types of images

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 24

Which filing system provides the most patient privacy?

A) alphabetical
B) subject
C) numerical
D) geographic

Question 25

How often should the tickler file be checked?

A) daily
B) several times a day
C) weekly
D) several times a month

Question 26

Match each example of information to the part of the medical record in which it would be found.
Patient's contact information (address, telephone number, etc.)

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 27

When filing alphabetically:

A) names are filed in a Z-to-A sequence from the first to the last letter
B) hyphenated surnames and hyphenated firm names are indexed as one unit
C) prefixes are not considered to be part of the surname
D) words such as and and for are disregarded and should be omitted

Question 28

Match each example of information to the part of the medical record in which it would be found.
Patient's immunization record from the previous provider

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 29

Match each example of information to the part of the medical record in which it would be found.
Breakdown of the drugs currently prescribed to a patient

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 30

When filing alphabetically, if two names are identical, the address is used to make the filing decision in which order?

A) street, city, state
B) state, street, city
C) city, state, street
D) state, city, street

Question 31

Match each term with its definition.
Designated individual who keeps track of which individuals have access to protected health information within a facility

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 32

Match each example of information to the part of the medical record in which it would be found.
Request-of-information letter from a patient's insurance company

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 33

Match each term with its definition.
Required before any information in a patient chart can be released

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 34

Match each example of information to the part of the medical record in which it would be found.
Referral form from another physician

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 35

When you purge a file, you:

A) update it
B) clean it out
C) correct information in it
D) make a copy of it

Question 36

Match each example of information to the part of the medical record in which it would be found.
Chronological record detailing a patient's progression during treatment

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 37

Match each term with its definition.
These indicate that a practice is utilizing the electronic record rather than just having a system in place in order to benefit from the federal incentive program

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 38

Match each term with its definition.
May offer the advantage of a treatment otherwise unavailable to a patient and additional care that might not have otherwise been provided

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 39

Match each example of information to the part of the medical record in which it would be found.
Copy of a patient's x-ray film

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 40

Match each example of information to the part of the medical record in which it would be found.
Patient's insurance policy number

A)administrative data
B)financial and insurance information
C)correspondence
D)referral
E)past medical records
F)medications
G)progress notes
H)diagnostic imaging information
I)lab information

Question 41

Match each term with its definition.
Chronologic file used as a follow-up method for a particular date

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 42

Match each term with its definition.
Sort

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 43

Match each term with its definition.
Method of charting that encourages a clinician to provide greater detail of the information obtained during the interview and examination

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 44

Match each term with its definition.
Coding

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 45

Match each term with its definition.
This should never be used when changing an incorrect entry in handwritten progress notes

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 46

Match each term with its definition.
Reprints are very often filed with this

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 47

Match each term with its definition.
Storing

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 48

Match each term with its definition.
Inspect

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 49

Match each term with its definition.
Indexing

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports

Question 50

Match each term with its definition.
May be used to expedite both filing and finding of folders

A)Privacy Officer
B)imaging
C)correction fluid
D)tickler file
E)physician's order
F)color coding system
G)clinical trials
H)CHEDDAR
I)cross-index
J)meaningful use performance measures
K)dictated reports