Deck 41: Medical Records Management

Question 1

Medical Office Business Procedures/Management

Answer 1

It seems like you're asking for information on Medical Office Business Procedures/Management, but your question is incomplete. To provide a full answer, I would need a specific question or topic within the realm of Medical Office Business Procedures/Management. However, I can give you an overview of common procedures and management practices in a medical office setting.Medical Office Business Procedures/Management typically involves the following aspects:
1. **Patient Scheduling and Registration**: Efficiently managing patient appointments to optimize the use of medical staff and facilities. This includes patient registration, collecting insurance information, and maintaining patient records.
2. **Billing and Coding**: Accurately coding procedures and diagnoses using standardized medical codes, such as ICD-10 and CPT, to process insurance claims and patient billing.
3. **Insurance Verification and Authorization**: Confirming patient insurance coverage and obtaining necessary pre-authorizations for procedures to ensure payment.
4. **Compliance**: Adhering to healthcare laws and regulations, such as HIPAA for patient privacy and OSHA for workplace safety.
5. **Financial Management**: Overseeing budgeting, payroll, and financial planning. This includes managing accounts receivable and payable, and negotiating with suppliers.
6. **Human Resources**: Hiring, training, and managing staff, ensuring that the office is adequately staffed with qualified personnel.
7. **Office Administration**: Managing day-to-day operations, including ordering supplies, equipment maintenance, and ensuring the office environment is organized and conducive to patient care.
8. **Quality Control**: Implementing procedures to monitor and improve the quality of care provided, including patient satisfaction and safety measures.
9. **Electronic Health Records (EHR) Management**: Utilizing EHR systems to maintain accurate and comprehensive patient records, and to streamline communication between different healthcare providers.
10. **Communication**: Ensuring effective communication within the office and with patients, including handling patient inquiries, complaints, and education.
11. **Strategic Planning**: Developing strategies to improve office efficiency, patient care, and business growth. This may involve marketing, community outreach, and adapting to changes in healthcare policies.
12. **Risk Management**: Identifying potential risks to the practice, including malpractice, and implementing strategies to mitigate these risks.
If you have a specific question within any of these areas or another aspect of Medical Office Business Procedures/Management, please provide more details so I can give you a more targeted answer.

Question 2

What usually happens to a paper medical record after the transition to an electronic medical record?

A) It is scanned into the electronic medical record and then destroyed.
B) It is scanned into the electronic medical record and then moved to storage.
C) Baseline data and recent information is scanned into the electronic record, and the paper record is moved to storage.
D) Baseline data and recent information is scanned into the electronic record, and the paper record is kept available for two to three years.

Answer 2

Baseline data and recent information is scanned into the electronic record, and the paper record is kept available for two to three years.

Question 3

Discuss applications of electronic technology in effective communication

Answer 3

not answered

Question 4

Discuss pros and cons of various filing methods

Question 5

Basic Keyboarding/Computer Concepts

Question 6

Identify types of records common to the healthcare setting

Question 7

Which of the following types of medical records may be reviewed to record statistical information?

A) Paper medical records
B) Electronic medical records
C) Both paper medical records and electronic medical records
D) Neither paper medical records nor electronic medical records

Question 8

Discuss all levels of governmental legislation and regulation as they apply to medical assisting practice, including FDA and DEA regulations

Question 9

Describe the implications of HIPAA for the medical assistant in various medical settings

Question 10

Explain how the following impact the medical assistant's practice and give examples (b. Malpractice, c. Statute of Limitations)

Question 11

Discuss filing procedures

Question 12

Identify both equipment and supplies needed for filing medical records

Question 13

Describe indexing rules

Question 14

Which of the following are true about both paper medical records and electronic medical records?

A) They provide for continuity of care.
B) They provide an ongoing record of the patient's state of health.
C) They are legal documents if there is a question about care given.
D) They usually include information form more than one source.
E) All of the above.

Question 15

Explore issue of confidentiality as it applies to the medical assistant

Question 16

By which of the following methods can information NOT be entered into an electronic medical record (EMR)?

A) Keyboard of a laptop computer
B) Screen display of a tablet computer
C) Virtual keyboard on a PDA or smartphone
D) Laser light pointer on a computer terminal in the examination room

Question 17

Medical Law and Ethics

Question 18

Discuss principles of using Electronic Medical Record (EMR)

Question 19

Identify systems for organizing medical records

Question 20

Describe various types of content maintained in a patient's medical record

Question 21

What is the second indexing unit in alphabetic filing?

A) First name
B) Last name
C) Middle initial
D) Second letter of the last name

Question 22

Which filing system used for paper medical records protects patient identity most successfully?

A) Subject
B) Alphabetic
C) Numeric
D) Cross-indexed

Question 23

If Mary Jane Mitchell marries John L. Walker, which of the following names might Mary Jane choose to use as her married name?

A) Mary Jane Walker
B) Mary Jane Mitchell
C) Mary Jane Walker-Mitchell
D) Mary Walker Mitchell
E) All of the above

Question 24

If the office is using a color-coded system, who needs to know the meaning of the colors in use?

A) All office staff
B) Both office staff and patients
C) Only the medical assistants
D) Office staff and staff of the insurance companies billed by the office

Question 25

In a paper medical record system, how are laboratory reports that are smaller than 9×12 inches often filed?

A) Using chart dividers
B) From the top as separate short pages
C) Using mounting sheets, with the oldest report in front on top
D) Using mounting sheets, with the oldest report at the back on the bottom

Question 26

When is it recommended that file folders used to hold paper medical records be broken down into two folders?

A) When the width of the folder reaches ¼ inch
B) When the width of the folder reaches ¾ inch
C) When the width of the folder reaches 1 ½ inch
D) When the width of the folder reaches 2 inches

Question 27

Using the alphabetic system of filing, what would "The Harris Office Supply Company" be filed under?

A) T
B) H
C) O
D) C

Question 28

What is always necessary if a paper medical record system is used?

A) A means to back up data every day
B) A means to lock the medical record storage cabinets or storage room
C) A means to maintain high humidity in the medical record storage area
D) Color-coded labels or file folders to facilitate identification of records

Question 29

Which of the following names would be filed first?

A) St. James, Anne Marie
B) St. Charles, Josephine
C) St. Joseph, Joseph
D) St. Elmo, Elmer

Question 30

Which of the following would be filed first?

A) Jones, Jane
B) Jones, Louise
C) Jones, Kristine
D) Jones, L. W.

Question 31

Which of the following is an indirect method of filing?

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

Question 32

What is an advantage of an electronic medical record system?

A) Inactive records are automatically removed from the system.
B) It is easier to preserve patient confidentiality.
C) It is less expensive to initiate than a paper record system.
D) Less space is required for record storage.

Question 33

What is used to hold the medical records if the medical office uses a paper medical record?

A) Vertical drawer file cabinets
B) Open-shelf filing units arranged horizontally
C) Shelf filing units with pull-down fronts
D) Lateral drawer file cabinets
E) All of the above

Question 34

What is a patient's surname?

A) First name
B) Last name
C) Middle initial
D) Professional title

Question 35

Which of the following names would be filed first?

A) David de Long
B) Winston De La Mare
C) Jacob De Laray
D) Martha Delmarven

Question 36

What is an outguide?

A) A stiff piece of paper or plastic that is placed in a file when a medical record is removed
B) A metal device that facilitates removing a medical record from the filing cabinet or shelf
C) A metal divider that is placed on file shelves at specified intervals to support the records
D) An index card that is filled out to identify who has taken a medical record from the file

Question 37

Which of the following is NOT an advantage of using a numeric filing system?

A) It is easier to preserve patient confidentiality.
B) It is easier to identify patients when several patients have the same name.
C) Fewer label colors are required to mark the medical records.
D) A separate system must be maintained to link the patient's name with the numbering system.

Question 38

What is an indexing unit in an alphabetic filing system for medical records?

A) The patient's full name
B) Each color-coded label placed on the medical record
C) Each part of a patient's name
D) Each letter of a patient's name

Question 39

What is an advantage of using color-coded labels or folders?

A) It preserves patient confidentiality.
B) It simplifies removal of inactive records.
C) It reduces the risk of misfiling.
D) It simplifies the process of creating the record.

Question 40

If two patients have exactly the same name, what information is used to put their medical records in order?

A) Birth date
B) Chronologic age
C) Birthplace
D) Street address

Question 41

Which of the following makes it easier to find a paper medical record that has been removed from the files?

A) Handing the paper medical record from one person to another until everyone who needs to use it is finished
B) Filling out a card to place in the outguide for every record that was removed
C) Placing medical records in stacks that have no more than five records each
D) Keeping the medical records in good repair by securing loose pages and mending tears
E) All of the above

Question 42

One of the challenges of an electronic medical record system is preventing unauthorized alterations and authenticating digital signatures.

Question 43

A sorter is a device that facilitates placing documents in alphabetic or numeric order.

Question 44

Which of the following is the least common method for backing up the electronic medical record?

A) DVD optical disks
B) External hard drive
C) External tape drive
D) Network storage

Question 45

If the subject method of filing is used for folders, which of the following would be filed first?

A) Bank accounts
B) Cleaning services
C) Pharmaceutical companies
D) Medical supply companies

Question 46

If the terminal digit filing system is used, which of the following medical record numbers comes first in the files?

A) 02-19-81-86
B) 19-44-01-10
C) 32-94-47-03
D) 72-81-19-02

Question 47

In what order are documents filed into the medical record?

A) The order in which they are received in the office
B) With the oldest date first
C) In reverse chronologic order (most recent first)
D) In random order

Question 48

How long should the medical records of minors be kept?

A) Indefinitely-no medical record should ever be destroyed.
B) Until the patient becomes 18 years of age.
C) Until the patient becomes 21 years of age.
D) Until the patient reaches the age of majority plus the number of years for the statute of limitations in that particular state.

Question 49

What determines the classification of "inactive" for a medical record?

A) State law
B) Federal regulations
C) Office policy
D) OSHA recommendations

Question 50

Which of the following should be avoided in a storage area for inactive medical records?

A) Relative humidity between 48% and 52%
B) Keeping lights off unless someone is actually present in the storage area
C) Dust and exposure to insects
D) Secondary aisles that are only 3 feet wide
E) All of the above

Question 51

When can a physician destroy a patient's file?

A) If the patient was treated only once.
B) When the record has been inactive at least seven years after the statute of limitations has expired.
C) If the patient transfers to another physician.
D) Legally, medical records can never be destroyed.

Question 52

If paper medical records are stored in file cabinets, it is more common to use lateral drawer file cabinets than vertical drawer file cabinets.

Question 53

If the terminal digit filing system is used, what is the first filing unit for the number 01-68-72-59?

A) 01
B) 59
C) 68
D) 72

Question 54

Electronic medical record systems in one medical office will be able to share information with all other electronic medical record systems.

Question 55

If a chronological numeric filing system is used, which of the following medical records comes last in the files?

A) 0219
B) 1944
C) 3294
D) 7281

Question 56

Why are inactive records removed from the active file area in most offices?

A) To avoid confusion between active and inactive files
B) To create more space for the records of new patients
C) Because they are no longer necessary for billing
D) To protect them from constant wear and handling

Question 57

Where should the medical assistant's paper tickler files be stored?

A) Near the inactive medical record files
B) In a locked cabinet
C) In a desk or file cabinet near where the medical assistant usually sits
D) In the patient waiting room

Question 58

File folders used for paper medical records are similar to looseleaf notebooks.

Question 59

What must occur before a piece of correspondence can be filed in a patient's paper medical record?

A) It must be indexed.
B) It must be coded.
C) It must be annotated.
D) It must be initialed by the physician.

Question 60

What is a guideline for the storage of backup copies of electronic medical records?

A) If possible, they should be stored off site in a secure location.
B) They should be stored in a locked file cabinet in the office.
C) Their storage area should always be protected from light.
D) They should be encrypted so that only the system administrator can load them into the computer.

Question 61

Most offices that use paper medical records place a sticker identifying the year of the patient's last visit on the outside of the chart to facilitate identifying active records.

Question 62

A large practice is more likely to use a terminal digit numeric filing system than a chronologic numeric filing system.

Question 63

The medical record of a Medicare patient must be retained for at least ten years after the last contact with the patient.

Question 64

If a patient has a hyphenated last name, it may be helpful to cross-index the medical record in an alphabetic filing system.

Question 65

In an alphabetic filing system, the name Helen Walker Durand would be filed after Helen Walker-Durand.