Question 1

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

Accepted Answer

Comprehensive systems for maintaining computerized patient records can be quite expensive to purchase and implement, depending on the size and complexity of the healthcare organization. The cost may include hardware, software, training, and maintenance.

Question 2

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

Accepted Answer

This is a widely recognized issue in the healthcare industry and a major barrier to achieving comprehensive and efficient electronic health information exchange.

Question 3

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

Accepted Answer

Following facility policies ensures consistency and accuracy in documentation, as well as adherence to regulations and standards. Using personal or non-standard abbreviations can lead to confusion and misinterpretation, potentially compromising patient safety. Referring to a medical dictionary or using abbreviations learned in medical terminology courses may be helpful, but ultimately facility policies should take precedence.

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.

Accepted Answer

Preparing written documentation in advance without seeing the patient can lead to errors and does not account for changes in patient condition or needs. Proper documentation should be done after assessing the patient to ensure accuracy and relevance.

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?

Accepted Answer

It is not ethical or legal to sign someone else's name on a patient chart. The chart is a legal document that serves as evidence of the care provided to the patient. If your coworker forgot to sign, he should be the one to complete the necessary documentation, and you should not risk compromising your professional integrity by signing on his behalf.

Question 6

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

Accepted Answer

Medical records are considered legal documents and can be used as evidence in court. They contain important information about a patient's health and treatment, which can be relevant in legal proceedings such as medical malpractice cases or worker's compensation claims. However, the release of medical records is subject to strict confidentiality laws and regulations.

Question 7

Flow sheets are forms for specialty needs.

Accepted Answer

Flow sheets are forms that are created to meet the specific needs of a particular specialty or workflow. They are used to track and document patient information, interventions, and outcomes in a structured format that is easy to understand and communicate among healthcare providers.

Question 8

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

Accepted Answer

Medical documentation is a vital component of the medical record, consisting of notes and documents added by health care workers to document patient care and treatment.

Question 9

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

Accepted Answer

Faxes can be less secure and efficient compared to modern digital methods of transferring patient records, such as encrypted email or secure electronic health record (EHR) systems, which also ensure better privacy and compliance with regulations like HIPAA.

Question 10

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

Accepted Answer

The source-oriented approach to medical recordkeeping organizes information by health care specialty, such as all the information from the cardiologist in one section and all the information from the neurologist in another section. It can be difficult to find all the information related to a specific health problem or body system in this type of organization.

Question 11

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

Accepted Answer

Medical charting should be done in pen, not pencil, in order to create a permanent record of the patient's medical information that cannot be erased or altered easily. If a mistake is made, it should be corrected using a single line drawn through the incorrect information and replaced with the correct information, with the date and initials of the person making the correction. This ensures that the original information is still visible and the correction is clearly documented.

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.

Accepted Answer

This is the correct definition of a medical record.

Question 13

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

Accepted Answer

The federal government provided funds under the Health Information Technology for Economic and Clinical Health (HITECH) Act to incentivize health care providers to adopt electronic medical record systems, particularly those who accepted Medicare and Medicaid patients.

Question 14

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

Accepted Answer

The answer of The physician's orders are the primary tool...

Question 15

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

Accepted Answer

Incomplete documentation can result in insurance companies denying payment to health providers, as it makes it difficult to verify the services provided and their medical necessity.

Question 16

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

Accepted Answer

A chief complaint is typically a statement made by the patient describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the medical encounter, usually stated in the patient's words. An increase in blood pressure noted by the healthcare provider is an objective finding, not a subjective complaint by the patient.

Question 17

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

Accepted Answer

Source-oriented charting organizes information according to the source of the information (e.g., nursing, physician, laboratory), making it potentially more difficult to track the timeline of patient care events compared to a continuous chronological record format, which organizes information by date and time, providing a clearer timeline of patient care.

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.?

Accepted Answer

This choice accurately and concisely records the patient's sleep pattern and is specific. The other choices are either too vague or imply the patient is actively seeking treatment for their sleep issue when this may not be the case.

Question 19

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

Accepted Answer

Burning is a secure method to dispose of documents containing confidential patient information, ensuring that the information is completely destroyed and cannot be reconstructed or retrieved.

Question 20

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

Accepted Answer

Writing direct quotes and enclosing the entry in quotation marks is the most accurate way to document a patient's statement about symptoms experienced. It ensures that the information is recorded exactly as the patient stated it.

Quiz 19: Documentation and Medical Records