Records Management Lap 18

Under HIPA mdecial record of a patient who is no longer seeking treatment is …
A closed record
Which type of filing storage is most commonly used for color-coded files
Open-shelf lateral files
Restricted medical records are best stored in what type of filing storage system?
Vertical file
Whic of the following supplies will allow Mary to secure the patient documentation inside the medical record file folder?
E Fastner
Medical offices that use the color-coded filing system file the patient names by…
Last name first, first name last
Which of the following patients or clients would be filed first alphabetically?
Lillian Hardee
Susie went to the patient file folder and it was not in the storage file. What would have assisted Susie with quick retrieval of the pagient file?
Out guide
What is the best way to track a file on a patient if you do not know the first name from the last name, such as the name John Howard?
Use a cross – reference guide
Choose the patient medical record number that represents numeric consecutive filing
000589
Which set of numbers has unit 1 underlined and represents a terminal-digit filing system?
44-23-90 (90 underlined)
Mr. Oetter’s medical record is no longer in use, but the physician feels it should be kept for legal purposes. What is the term for this type of record?
Archieved record
This is a record of numbers assigned to each new patient record.
Accession log
What is an advantage in using the electronic health record (EHR) ?
Increases access to the medical record
You must remember to contact Mr.Clarke to schedule a repeat colonosopy in 1 year. What is the best reminder method ?
Tickler file
HIPAA privacy principles refers to
Protected health information
Which of the following PHI can be disclosed by the medical office without the patients permission?
The medical practices treatment, payment, and operation information
Under HIPAA, the patient has the right to request
Access to his or her medical information
An attorney phones and requests the medical record of a patient, Mr. Markett, to be sent to his office. What should the medical assistant do?
Phone the patient and request written consent before releasing information
One of the advantages of using folder labels that display the current year is that the
label makes it easier to remove Records of active patients to inactive status
Which of the following items would make shingling an easy task
Mounting sheets
Filing manual records can be time consuming. What can help to move this tedious task along
Usinga sorter
Which of the following should be performed first when filing a paper patient medical records
Conditioning
What should happen before records or reports are filed in the medical chart
The position should sign off or initial the report and perform any necessary action
Ownership of the information in the patient medical
The patient
When can the original physical medical record be released
When the medical record is subpoenaed by a court of law
The patient’s statement that “there is a serious pain in the left upper portion of my abdomen” refers to which part of the SOAP format
Subjective information
We represent the position conclusion about the patient’s condition
Assessment
which term demonstrate patient understanding of the overall plan of treatment
Evaluation
Which statement is true regarding the statute of limitations for retaining a patient’s medical records
Each health care providers should know the statutes in his or her practicing States
Drug Enforcement Agency DEA a controlled substance abuse records should be kept
Indefinitely
Choose the documentation format that is the traditional system found in most medical offices
SOMR
which documentation format organizes patient data in a logical manner
POMR
The medical record contains two main type of patient information what are they
Personal information and clinical information
Select the correct way to end a chart notes
The patientC/O mild HAs and severe cough ———-M.Hill, CMA
The workers compensation chart belongs to the
Employer
The notes on each page of the patients progress sheet with in the medical records are written
In chronological order
When treating a patient who was injured on the job the medical information
Must be in a separate medical record in a separate location
Which of the following could help the physician with the lawsuit
Making correct clear legible and timely entries in the medical record
The sender medical record is generally organized
According to the physician preferences
The electronic medical record software allows the healthcare provider to
Imput administrative financial and clinical information
Which system is the best for filing non-patient related files
Subject filing system
What is the best way to store large volumes of inactive patient files
using microfilm
Select a special circumstance that require specific permission from the patient to release medical record information
Reference to drug or alcohol abuse entry
Which of the following statement is true
A patient must get permission from the emancipated minor to access medical information concerning the child
Locate a potential concern when converting paper medical records into an electronic health record
Ever in 2012 in putting information into EHR format
A HIPAA guidelines to follow when creating a paper medical records is to
Have no visible personal health information on the outside of the charts
Other than patients medical records what type of information is considered a legal document in the medical practice
Appointment book or computerized appointment pages
216 endeavor flex documentation that is in addition to the SOAP format
Focuses on the evaluation of the patient’s response to intervention