Question 1

A patient's electronic medical record is used:
A) To assist in streamlining the sharing of medical information
B) To give healthcare providers access to patient medical information
C) To assist in preparation of health care statistics and research
D) All of the above

Accepted Answer

Electronic medical records are used to streamline the sharing of medical information, give healthcare providers access to patient medical information, and assist in preparation of healthcare statistics and research.

Question 2

Through networks,the EHR can:
A) Allow patient's health information to be seen by anyone,anywhere
B) Prevent duplication of lab testing and treatments
C) Prevent polypharmacy
D) Both B and C

Accepted Answer

Through networks, the EHR can prevent duplication of lab testing and treatments as well as prevent polypharmacy. However, allowing patient's health information to be seen by anyone, anywhere is not always the case as there are strict laws and regulations regarding patient privacy and confidentiality.

Question 3

Most physician office narrative records are kept in reverse chronological order,which means:
A) The records are in date order from the first patient visit
B) The most recent encounters are the first documents that you see
C) The record is divided by departments
D) The filing system keeps most recent patients at the beginning

Accepted Answer

Reverse chronological order means that the most recent encounters are the first documents that you see when looking at a patient's record.

Question 4

Who owns the patient's medical records?
A) The patient
B) The insurance company
C) The facility where the patient is treated
D) HIPAA

Accepted Answer

The facility where the patient is treated owns the physical or electronic medical records, although patients have rights to access their health information under HIPAA regulations.

Question 5

The patient's medical record serves as:
A) Written communication between you and other healthcare professionals
B) A legal account of the patient's care
C) The patient's response to care given
D) All of the above

Accepted Answer

The patient's medical record serves as a written communication between healthcare professionals, a legal account of the patient's care, and a record of the patient's response to care given. It is important to maintain accurate and complete medical records to ensure continuity of care and protect the patient's privacy and legal rights.

Question 6

What do many physicians worry about in relation to EHRs?
A) Privacy
B) Hackers
C) Costs
D) All of the above

Accepted Answer

Many physicians worry about all of the above concerns related to electronic health records (EHRs). The use of EHRs can potentially compromise patient privacy, especially if the system is not properly secured against hackers. Additionally, implementing and maintaining EHR systems can be costly, which is a major concern for many healthcare providers.

Question 7

Of the following conditions,which one requires a special authorization for release of information?
A) HIV status
B) Alcohol use or abuse
C) Drug use or abuse
D) All of the above

Accepted Answer

All of the above conditions (HIV status, alcohol use or abuse, and drug use or abuse) require special authorization for the release of information due to their sensitive nature and the privacy laws protecting such information, such as HIPAA in the United States.

Question 8

The use of multiple medications by a patient is known as:
A) Multidrug use
B) Polypharmacy
C) Polyprescriptive
D) Overmedication

Accepted Answer

Polypharmacy is the use of multiple medications by a patient. It can lead to potential drug interactions, adverse effects, and compromised adherence to medication regimens. This term is commonly used in healthcare to describe the situation where a patient is prescribed multiple medications for various health conditions.

Question 9

Acute care and long-term facilities keep records in chronological order,which means:
A) The beginning of the patient's care is at the beginning of the record
B) The record is compartmentalized
C) Most recent entries are at the beginning of the record
D) Tabs are placed on the record for each entry

Accepted Answer

Chronological order means that the records are arranged in the order in which events occurred, starting with the earliest event and ending with the most recent. In this case, the beginning of the patient's care would be the first entry in the record.

Question 10

What may impact the decision for some physicians and healthcare facilities to convert to the EHR?
A) Frustration with electronics
B) Costs
C) Lack of privacy for records
D) Space for the computer stations

Accepted Answer

The cost of converting to the EHR system can be a significant barrier for some physicians and healthcare facilities. The cost includes the purchase of hardware, software, and training, as well as potential productivity and revenue losses during the transition period. Frustration with electronics, lack of privacy for records, and space for computer stations may also be concerns, but they are not the most significant factors in the decision to convert to the EHR.

Question 11

Which of the following notes is written correctly?
A) I took the patient's vital signs
B) Vital signs taken
C) Mrs.Brown's vital signs were done
D) I went to the patient's room to take her vital signs
Completion
Complete each statement.

Accepted Answer

The answer of Which of the following notes is written...

Question 12

Information contained in the medical record includes all of the following except:
A) Demographic information
B) Vital signs
C) Your personal opinion
D) Lab/x-ray reports

Accepted Answer

Personal opinions do not belong in a medical record as they are subjective and not objective observations or medical data. The medical record should only contain factual and objective information related to the patient's medical history and current condition.

Question 13

The electronic health record (EHR)should:
A) Cost less than paper
B) Make documentation more complex
C) Improve patient care
D) Reduce the amount of documentation

Accepted Answer

The aim of implementing EHRs is to improve patient care. By having a patient's medical records stored electronically, healthcare providers can access their medical history quickly and make informed decisions about their treatment. Additionally, EHRs can help reduce medical errors and enhance communication between healthcare providers. While the cost of implementing an EHR system can be high, the intention is not to make documentation more complex or to reduce the amount of documentation, but to make it easier to access and more efficient.

Question 14

What is one item that may help clarify a situation for all who are involved in the patient's care?
A) Your detailed description written in the progress notes
B) A patient's quote
C) A note at the nurse's station to explain the details
D) A drawing

Accepted Answer

The answer of What is one item that may help...

Question 15

Which of the following entities may get copies of your record without your written consent?
A) Your school
B) Your worker's compensation carrier
C) Your spouse
D) Your potential employer

Accepted Answer

Worker's compensation carriers may access your records without consent as part of processing claims related to workplace injuries.

Question 16

The best method of correcting an error in a patient record is:
A) Using correction fluid
B) Scribbling through the entire error
C) Striking through with a single line,providing date and a simple explanation
D) Using a dark marker to obliterate the error

Accepted Answer

Striking through with a single line and providing date and a simple explanation is the best method of correcting an error in a patient record. This allows for the error to be easily identified and ensures that the correct information is still visible in the record. Using correction fluid or a dark marker could make the record difficult to read and potentially lead to confusion or mistakes in future treatment. Scribbling through the entire error is also not recommended as it could make it difficult to determine what the original information was.

Question 17

The most common format for recording a patient's health information is:
A) Exceptional
B) Listing
C) Paragraphs
D) Narrative

Accepted Answer

Narrative format is the most common and traditional format for recording a patient's health information. It involves writing a chronological description of the patient's history, including symptoms, diagnoses, treatments, and outcomes. This format is useful for creating a complete picture of the patient's health and progress over time.

Question 18

A continuous narrative summary of the patient's care by physicians,nurses,and other healthcare professionals is the:
A) Flowchart
B) Progress notes
C) Medication record
D) Problem list

Accepted Answer

Progress notes are entries made by healthcare professionals that document a patient's care over time. They provide a continuous narrative summary of the patient's condition, treatments, and progress. Flowcharts are graphical representations of a patient's care, medication records document the medications prescribed to a patient and their administration, and problem lists identify the patient's active and chronic health conditions.

Question 19

A format for documenting repeated medical information,such as vital signs,separate from the narrative summaries is:
A) By exception
B) Narrative
C) Flowcharts
D) Graphic modules

Accepted Answer

Flowcharts are used to document repeated medical information, such as vital signs, in a structured format that allows for easy tracking of changes over time, separate from narrative summaries.

Question 20

The initial government mandate was for all healthcare providers to convert to an electronic format by:
A) 2000
B) 2010
C) 2014
D) 2024

Accepted Answer

The initial government mandate was for all healthcare providers to convert to an electronic format by 2014, as part of the American Recovery and Reinvestment Act (ARRA) passed in 2009. This initiative aimed to improve the efficiency and effectiveness of healthcare delivery by ensuring more accurate and accessible patient records, reducing medical errors, and facilitating clinical decision-making.

Quiz 18: Documentation

A patient's electronic medical record is used:

Through networks,the EHR can:

Most physician office narrative records are kept in reverse chronological order,which means:

Who owns the patient's medical records?

The patient's medical record serves as:

What do many physicians worry about in relation to EHRs?

Of the following conditions,which one requires a special authorization for release of information?

The use of multiple medications by a patient is known as:

Acute care and long-term facilities keep records in chronological order,which means:

What may impact the decision for some physicians and healthcare facilities to convert to the EHR?

Which of the following notes is written correctly?

Information contained in the medical record includes all of the following except:

The electronic health record (EHR) should:

What is one item that may help clarify a situation for all who are involved in the patient's care?

Which of the following entities may get copies of your record without your written consent?

The best method of correcting an error in a patient record is:

The most common format for recording a patient's health information is:

A continuous narrative summary of the patient's care by physicians,nurses,and other healthcare professionals is the:

A format for documenting repeated medical information,such as vital signs,separate from the narrative summaries is:

The initial government mandate was for all healthcare providers to convert to an electronic format by: