Deck 13: Medical Records Management

Question 1

Which of the following best describes the primary use of out guides?

A)Patient reminders
B)Chart removals  
C)Cross references
D)Numeric files  
E)Purged records

Answer 1

Chart removals  

Question 2

Which of the following is NOT essential equipment needed with a numeric filing system?

A)Consecutive numbered guides
B)Miscellaneous numeric section  
C)Outguide
D)Alphabetic card file  
E)Accession record

Answer 2

Outguide

Question 3

Which of the following is a filing tool used to track a patient's chart removed from the storage area?

A)File folder
B)Identification label  
C)Out sheets
D)Index unit  
E)Cross reference

Answer 3

Out sheets

Question 4

Which of the following best describes the tab-alpha system?

A)Lateral moveable files
B)Combination of 13 colors  
C)Full-cut folders and a color-coded label
D)Ten colors and 1/3-cut folders

Question 5

A unit identifies each part of a name.The key unit is also known as what?

A)No unit
B)Unit 1  
C)Unit 2
D)Unit 3

Question 6

How would Henry Patrick Hays IV be filed in relation to Henry Patrick Hays Jr.?

A)Before
B)After  
C)Depends on the birthdays
D)By address to separate

Question 7

Which of the following best describes the process of sorting through records and removing those that are not active?

A)Reminder system
B)Check-out  
C)Cross-reference
D)Closed files  
E)Record purging

Question 8

Which of the following is NOT a type of color-coding system?

A)Tab-alpha
B)AlphaZ®  
C)Customized color coding
D)Tab-beta-a

Question 9

Which of the following is a coding system NOT commonly used in ambulatory care centers?

A)Alphabetic
B)Geographic  
C)Numeric
D)Subject

Question 10

Which of the following is a filing method used to identify and separate items to be filed in small subunits?

A)File folder
B)Identification label  
C)Out sheets
D)Indexing units  
E)Cross reference

Question 11

How many indexing units apply to the name and title, John W.Williams, M.D.?

A)One
B)Two  
C)Three
D)Four  
E)Five

Question 12

There are how many Rules to be followed when filing a patient's chart?

A)5
B)8  
C)9
D)4

Question 13

Which of the following best describes a filing method that serves as a reminder for future actions?

A)Shingling
B)Purging  
C)Indexing
D)Tickler  
E)Release

Question 14

Medical facilities generate a large amount of information.The greatest bulk of it comes from what?

A)Insurance
B)Personnel  
C)Medical records
D)Financial records

Question 15

When an error has been made and you need to correct a medical record, what must be done?

A)Use Wite-Out® to cover the error and rewrite. 
B)Use a single red line and your initials. 
C)Cross out with a black pen. 
D)Do nothing and continue writing.

Question 16

Which of the following statements does NOT best describe the importance of accurate medical records?

A)They are essential to patient care. 
B)They assist in controlling the costs of medical care. 
C)They may be released without a patient's knowledge. 
D)They are needed to provide referrals. 
E)They maintain a conscientious record of patient care.

Question 17

Which of the following is considered primary information found on an outguide?

A)Full name of the doctor
B)Diagnosis of the patient  
C)Person having possession
D)Reason chart was removed

Question 18

Which of the following best describes the primary use of cross-reference filing?

A)Placing outguides
B)Identifying location of a file  
C)Establishing a card file
D)Using only for marriages and name changes

Question 19

Which of the following is NOT an appropriate action to locate missing files?

A)Check files before and after the misplaced file. 
B)Check physician's tray and desk. 
C)Check files with same color-coding system. 
D)Check all outguides. 
E)Check for transposition of first and last names.

Question 20

Which of the following best describes how titles are considered when alphabetizing and assigning units for filing order?

A)Part of the last name
B)Separate unit at the end  
C)Not a unit
D)First unit

Question 21

What is the most common document that will be a part of the patient chart?

A)Clinical notes
B)Correspondence  
C)Lab reports
D)All of the above

Question 22

Which of the following is considered a disadvantage of electronic medical records?

A)Multiple users are possible.
B)Office storage is not required. 
C)On-site assistance may be required.
D)Patterns and data are more easily accessed.

Question 23

When using a tickler file, what should be listed on the reminder?

A)Tickler date
B)Required action  
C)Patient name
D)All of the above

Question 24

Which of the following best describes records that need to be readily accessible for retrieval of information?

A)Active
B)Inactive  
C)Closed
D)Cross-referenced

Question 25

In President George Bush's 2004 Health Information Technology Plan, he included the goal that most Americans would have electronic health records by what year?

A)2020
B)2014  
C)2012
D)2008

Question 26

Which of the following is the appropriate indexing unit for St.Ann's Hospital?

A)St.Ann's Hospital
B)Stanns Hospital  
C)Saint Anns Hospital
D)Saintanns Hospital

Question 27

Which of the following is used in numeric filing as a journal or computer listing in which numbers are preassigned?

A)Accession record
B)Alphabetic card file  
C)Serial file
D)Consecutive file

Question 28

Which of the following is the most appropriate format for a patient's name on a medical chart?

A)Nickname
B)Legal name  
C)Last name, first name
D)Abbreviation

Question 29

Which of the following filing systems would be most appropriate when you have a large number of patients?

A)Alphabetic
B)Geographic  
C)Numeric
D)Subject

Question 30

Which method of arranging charts uses a page that lists vital identification data, immunizations, allergies, medications, and problems?

A)Problem-oriented medical record (POMR)  
B)Source-oriented medical record (SOMR)  
C)Strict chronological arrangement  
D)Shingling

Question 31

Which of the following medical record formats does NOT contain a problem list?

A)POMR
B)SOAP  
C)SOMR
D)SOAPER

Question 32

Which of the following is the appropriate place for filing an item that does not have enough in number to warrant an individual folder?

A)Incoming correspondence
B)Outgoing correspondence  
C)Miscellaneous
D)Dead letter

Question 33

What is NOT considered to be an advantage of the Manual Medical Record?

A)Currently established and understood
B)Easier to protect confidentiality  
C)No worry of computer malfunction
D)Can be used by only one person at a time

Question 34

Which of the following is NOT considered when choosing a patient filing system?

A)Primary filing objectives
B)Number of expected patients  
C)Confidentiality
D)Amount of cross-referencing needed

Question 35

The management of the medical record must:

A)Provide easy retrieval
B)Have a format that is easily understood by all  
C)Have all documentation complete and correct
D)All of the above

Question 36

Which of the following is NOT a type of filing cabinet used in medical clinics?

A)Vertical 
B)Lateral  
C)Movable 
D)Horizontal

Question 37

Which of the following would apply to the legal standard if there is no written record of a temperature, a visit, a history, a physical, or a lab report?

A)It was not written down, so it did not happen. 
B)The court will take the patient's word for it. 
C)The court will take the provider's word for it. 
D)The court will make the decision as to whether or not it happened.

Question 38

Who is responsible for developing basic indexing rules for filing?

A)AMA
B)ASCP  
C)AMRA
D)AAMA

Question 39

When EMRs from multiple sources are combined into one database for a patient, what term is used?

A)EHR
B)EMR  
C)ERS
D)None of the above

Question 40

Which type of medical record has data filed strictly with the most recently charted materials at the top of the folder?

A)Problem-oriented medical record (POMR)  
B)Source-oriented medical record (SOMR)  
C)Strict chronological arrangement  
D)SOAP

Question 41

Which of the following steps for filing medical documentation is NOT helpful?

A)Inspect
B)code  
C)Index
D)all of these are helpful

Question 42

Match the following choices with the statements below.

equally distributed files

A) alphabetic filing
B) numeric filing

Question 43

Match the following choices with the statements below.

simplest filing method

A) alphabetic filing
B) numeric filing

Question 44

Match the following choices with the statements below.

used when a limited number of files is accessed

A) alphabetic filing
B) numeric filing

Question 45

Match the following choices with the statements below.

have straight and terminal systems

A) alphabetic filing
B) numeric filing

Question 46

When traditional paper-based charts are used, HIPAA compliance mandates no identifiable patient information should be located on the outside of the chart.This information includes all of the following except:

A)Social security number  
B)Date of birth  
C)Address  
D)All of the above information should not be placed on the outside of the chart

Question 47

What additional letters have been added to medical facilities using the SOAP approach to charting?

A)ED
B)EN  
C)ES
D)ER

Question 48

Match the following choices with the statements below.

preserves patient confidentiality

A) alphabetic filing
B) numeric filing

Question 49

The middle pair of digits in the middle-digit filing system are considered which of the following?

A)Primary
B)Secondary  
C)Third
D)None of the above

Question 50

Which of the following is a step for cross-referencing a file?

A)Identify the primary filing label. 
B)Make a proper file to be used as the primary location. 
C)Identify an alternative where one might find the file. 
D)All of the above.

Question 51

Match the following choices with the statements below.

labels assigned to each file

A) alphabetic filing
B) numeric filing