Deck 19: Documentation and Medical Records

Question 1

Comprehensive systems for maintaining computerized patient records are fairly inexpensive to purchase and implement.

Answer 1

False

Question 2

A major difficulty with electronic medical records is the inability of the systems from different manufacturers to communicate and share information.

Answer 2

True

Question 3

How should the health care professional select appropriate abbreviations to use in written documentation?

A) Create personal abbreviations that are clear.
B) Refer to a standard medical dictionary.
C) Use those learned in medical terminology courses.
D) Follow facility policies.

Answer 3

Follow facility policies.

Question 4

A good way for health care professionals to increase their efficiency is to gather all the records for patients to be seen that day and prepare the written documentation in advance for procedures to be done during the day.

Question 5

A coworker calls from home and asks you to sign his name on a patient chart that he forgot to sign after administering a medication. What should you do?

A) Sign his name.
B) Sign your name.
C) Sign both your names.
D) Refuse to sign either name.

Question 6

Medical records are legal documents that can be used as evidence in court.

Question 7

Flow sheets are forms for specialty needs.

Question 8

Medical documentation refers to notes and documents that health care workers add to the medical record.

Question 9

Faxes are a good way to efficiently send patient records to another provider.

Question 10

Which method of organization describes the source-oriented approach to medical recordkeeping?

A) Chronological order
B) By health care specialty
C) By the type of health problem
D) By the body system affected

Question 11

Medical charting should be done in pencil because mistakes can be more easily and neatly corrected.

Question 12

A medical record refers to the collection of all documents that are filed together and form a complete chronological health history of a particular patient.

Question 13

The federal government provided funds health care providers who accepted Medicare and Medicaid patients to set up electronic medical record systems.

Question 14

The physician's orders are the primary tool used to record, communicate, and coordinate the care given to the patient.

Question 15

Incomplete documentation can result in denial of payment to health providers by insurance companies.

Question 16

An example of a chief complaint would be when the health care provider notes an increase in blood pressure that requires treatment.

Question 17

Source-oriented charting format is a better approach than continuous chronological record format.

Question 18

What is the best way to record in a patient's report that he only slept from about 1:00 a.m. to 4:30 a.m.?

A) Patient reports difficulty sleeping.
B) Patient is sleeping poorly.
C) Patient states, "I only slept 3 ½ hours last night."
D) Patient needs help sleeping.

Question 19

Which of the following methods is appropriate for disposing of documents that contain confidential patient information?

A) Office waste basket, as long as the room is secure
B) Hazardous waste bag
C) Burning
D) Facility waste container, such as a dumpster

Question 20

Which is the correct way to document a patient's statement about symptoms experienced?

A) Write direct quotes and enclose the entry in quotation marks.
B) Write the statement in your own words.
C) Note the statement in a shortened form, using standard abbreviations.
D) List the symptoms, using correct medical terminology.

Question 25

Which of the following is true about HIPAA?

A) It prevents patients from viewing their medical records.
B) It is a sophisticated medical management software program.
C) The government mandates that all health care providers follow HIPAA rules.
D) It contains safeguards for both care providers and patients.

Question 26

Every entry on a medical record must include the time, date, and ________________ of the health care professional who made the entry.

Question 27

Which of the following items would be part of the familial history?

A) Assessment of body systems
B) Medical problems of relatives
C) Frequency of alcohol use
D) Past surgeries of patient

Question 28

Which of the following personnel may write progress notes that are included in the patient's official medical record?

A) Only physicians
B) Only nurses
C) Only physicians and nurses
D) Any health care professional who provides a direct service to the patient

Question 30

Which of the following items would be included in the personal history?

A) Allergies
B) Smoking history
C) Family tendency for problems
D) Use of illegal drugs

Question 31

Which of the following statements are true about personal health records (PHR)?

A) Include an assessment of body systems
B) Computerized information used by health care systems
C) Required by law
D) Documents are created and maintained by the individual

Question 32

Which of the following is a purpose for medical documentation?

A) Prevents malpractice lawsuits
B) Prevents cost overruns
C) Communicates directly with the patient
D) Helps ensure compliance with regulatory agencies

Question 35

Which of the following is the best definition of charting?

A) Forms a complete chronological health history of a particular patient
B) Collection of all documents that are filed together
C) Provides legal protection
D) Records observations and information about patients

Question 36

Which of the following is considered by some experts to be the most serious problem with electronic health records?

A) Patients don't trust
B) Cost of implementation
C) Cyberthreats
D) Difficulty training staff

Question 39

A major component of HIPAA is to:

A) ensure that Medicare patients receive proper care.
B) protect the privacy of patient records.
C) control health care costs.
D) provide guidelines for patient safety.

Question 41

The health care professional can help protect patient privacy by using a strong computer _____, changing it regularly, and never giving it to anyone.

Question 42

When using the method known as "charting by exception," only __________ findings are noted.

Question 43

Medical documentation that is  _____________ illegibly is useless and may cause legal problems.