Deck 15: The Health Record

Question 1

Which of the following is necessary when correcting or making additions to paper medical records?

A) Draw a single line through the error.
B) Make the correction as close as possible to the original entry.
C) Note the reason for the correction and sign and date the correction.
D) A witness should also initial the entry.
E) a-c are required; d is advisable.

Answer 1

There is a possibility that the record could become a legal problem if changes to the medical record are not made correctly. Even in medical records, the mistakes may be made by the professionals.
For correcting any mistake in a medical record, carefully a single line should be drawn through the error. The corrected information should be typed as close as possible. It might be written above or below the original entry or even in the margin.
Hence the incorrect options are a, b, c, and d.
The date and reason should be noted while correcting. The initial or signature should be done near to the completed correction. It is advised to have the witness while making the correction and his/her initials should also be taken near to the corrections.
Hence the correct option is
.

Question 2

Which of the following disadvantages of the EHR may affect smaller medical practices?

A) Cost
B) Fear of technology
C) Possible need for an IT specialist
D) Training requirements
E) All of the above

Answer 2

The use of electronic health records (EHR) or electronic medical records (EMR) is gaining importance for providing quality health care. These are also essential for the improvement of the safety of the patient. The use of these records offers several advantages as well as disadvantages.
The main concern or disadvantages are related to the cost of maintaining such software in an organization. It requires training the entire staff members in a new manner. It becomes essential to appoint staff members of the IT department.
Hence the incorrect options are a, b, c, and d.
For some time, the work rate slows down until the staff members are thorough with the system. This sometimes creates anger and frustration among the staff members. It also requires making the patient understand the system.
Hence the correct option is
.

Question 3

Which of the following is not an advantage of EHR?

A) Multiple providers may access one record at the same time.
B) Records are easily accessed.
C) There are multiple software vendors for HER with varying requirements.
D) Records are secured through passwords and access codes.
E) Information is available in real-time.

Answer 3

The use of electronic health records (EHR) or electronic medical records (EMR) are gaining importance for providing quality of health care. These are also essential for the improvement of safety of the patient. The use of these records offers number of advantages as well as disadvantages.
The advantages include ease of accessibility of records by multiple providers at the same time. The records are secured through passwords and access codes. The information can be available in the real-time by the use of EHR.
Hence, the incorrect options are a, b, d and e.
The presence of multiple software vendors for EHR with varying requirements is not advantageous for this system. Instead it is a disadvantage because it would lead to variation in records of different organizations.
Hence, the correct option is
.

Question 4

Role-play in groups of three students. One student should play the patient, one the administrative medical assistant, and one the observer. Role-play a scenario in which the patient requests to have her medical records released to another physician.
The administrative medical assistant should explain to the patient the process for the release of her medical records.
The observer should not speak but should observe and take notes on the scenario as acted out by the other two students. The observer should compare the scenario to the steps provided in the text for the release of records. Note what is done well and what needs improvement.
Each student should rotate through all three roles.

Question 5

A patient's illness and reason for visit to the physician would be found in the

A) patient's medical history.
B) records from other health-care providers.
C) patient registration form.
D) informed consent form.
E) physical examination.

Question 6

What might have happened on a follow-up visit if Alicia did not ensure information for patients seen on the "go live" date was input into the EHR?

Question 7

The first document(s) found in a patient medical record is the

A) patient registration form.
B) doctor's diagnosis and treatment plan.
C) patient medical history.
D) records from other physicians or hospitals.
E) patient physical examination.

Question 8

Photocopy the blank combination medical history and physical examination form shown in Figure 15-4. Fill out the form by using the following patient information:
For medical history section: Date: 2/14/12; the patient is Heather R. MacEntee, age 35, living at 344 Westwind Lane, Apartment 28, Round Tree, IL 60012; telephone [phone]. She is a real estate broker, married, with a 6-yearold child. Her father died at age 55; her mother is 62 and has congestive heart disease. She has no siblings. The family has a history of heart disease and diabetes. The patient had chickenpox and mumps at age 7 and surgery for an ovarian cyst at 22. She has an allergy to ragweed but is not taking any medications at present.
For physical examination section:
Ms. MacEntee weighs 142 lb, is 5 ft 10 in tall, and her temperature and respiration are normal. Her pulse is 74, her blood pressure is 110/75, and her chest sounds are normal.
Her chief complaint is discomfort in the area of the gallbladder. She has intense pain after eating. Blood tests are normal. The doctor's initial impression is suspected gallstones, and an ultrasound scan of the gallbladder is ordered. Treatment plan depends on the scan results.

Question 9

What are some of the advantages the EHR has over the hard-copy medical record?

Question 10

All of the following are uses for medical records EXCEPT

A) research.
B) quality of care.
C) patient education.
D) All of the above.
E) b and c only.

Question 11

What are some of the concerns regarding the EHR?

Question 12

POMR stands for

A) Patient-Oriented Medical Record.
B) Problem-Obvious Medical Record.
C) Problem-Oriented Medicine Record.
D) Patient-Oriented Medicine Record.
E) Problem-Oriented Medical Record.

Question 13

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

A) Completeness
B) Clarity
C) Conciseness
D) Chronological order
E) Client's words

Question 14

Why is it important to ensure that the medical history form is filled out completely and accurately?

A) It cuts down on the questions the physician must ask.
B) Less testing will need to be done to understand the patient's complaint.
C) It is an ice-breaker for difficult discussions between the patient and physician.
D) It is the basis for the rest of the patient medical record.
E) All of the above.

Question 15

Why is blue ink preferred (by HIPAA recommendations) for medical record documentation?

A) It photocopies in the original color.
B) It is easy to duplicate exactly when amending information.
C) It is easy to differentiate between the original and a copy.
D) It is a legal requirement.
E) It is usually readily available.