Chapter 11 Test Review

Which of the following is not a method of organizing a medical record?

Information that is gained by questioning the patient or that is taken from a form is called ________________ information.

Which of the following is not needed when describing a patient's chief complaint?

A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files is called a(n) _____________ system.

How would you properly index the name "Jill Freeman, M.D." for filing if you had another patient with the same name but without the title?

How would you properly index the name "Amanda M. Stiles-Duncan" for filing?

Who is the legal owner of the information stored in a patient's record?

Continuity of care means

Which of the following are common types of filing equipment found in a medical office?

Which of the following is not an advantage of color-coded filing systems?

Which statement is not true regarding the reasons for keeping accurate medical records?

Which of the following is not objective information?

What is the most important reason for telling the physician when a charting error is discovered later?

Which statement is not accurate about correcting charting errors?

The medical record should be released only with a

Medical facilities should keep records on minors for how long?

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

Many healthcare facilities now use voice recognition software for transcription. The system can be used to dictate which types of reports?

The most frequently used follow-up method is a

Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files.

HIPAA recommends that physicians keep the records on patients for at least

The medical assistant should consider which of the following when selecting filing equipment?

A strong, highly glazed composition paper or heavy card stock is called

The process of moving an active file to inactive status is called

The physical medical record belongs to the

A correction to a medical record can be made by

The "E" entry in the SOAPER charting method means

The "R" entry in the SOAPER charting method means

The preferred filing method for a physician's office is

The newest component used today to complete transcription and authenticate records is __________ software.

Who ultimately decides whether a medical record can be released?

Advantages of the EHR system include

Disadvantages of the EHR system include

A set of physical properties, the values of which determine characteristics or behavior, is called

The type of electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff from more than one healthcare organization is a(n)

The type of electronic record of health-related information about an individual that can be created, gathered, managed, and consulted only by authorized clinicians and staff in a single healthcare organization is a(n)

How are corrections made to the electronic health record?

How can the EHR function to best help improve a facility's appointment show rate?

Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to

Which EHR system backup is probably the least trouble and requires the least amount of hardware?

Medical assistants can encourage other staff members during a conversion to an electronic health record system by

In most cases, does the electronic health record system require more or less storage space than a paper filing system?

Who is responsible for calming patients' fears and concerns about switching to an electronic medical record system?

What is one of the benefits of using a paper health record?

Which section of the law, commonly known as the Economic Stimulus Package, pertains to healthcare?

For a record to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written. The best indication of this is the provider's signature or initials on the typed or EHR entry.

Improved outcomes is part of which of the stages of meaningful use?

Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology?

What is the HIPAA privacy rule requirement for the retention of health records?

Which of the following health information exchanges allows providers to find and/or request information on a patient from other providers?

In a paper record, which of the following is never an acceptable method of correction to a handwritten entry?

Which of the following indirect filing systems is used by a majority of large clinics and hospitals?

__________ information is provided by the patient.

To make greater, more numerous, larger, or more intense is to __________.

When a patient is transferred from one facility to another, __________ of care ensures that no lapses in treatment occur and that transitions are smooth.

__________ of an entry in a medical record is never acceptable.

The concise account of the patient's symptoms in his or her own words is the __________.

To be granted or endowed with a particular authority or right is to be __________.

__________ information is observed by the physician.

A(n) __________ file is a follow-up system used to help the medical assistant remember when a certain task needs to be done.

Deciding where to file a particular chart based on the patient's name is called __________.

A filing system that uses a combination of letters and numbers is said to be __________.

The __________ diagnosis is temporary and is made before test results have been received.

A(n) __________ is made of heavy paper stock and is used to replace an entire folder that has been temporarily removed from its proper place.

Information picked up bit by bit is said to be __________.

A filing system in which an intermediary source of reference, such as a card file, must be consulted to locate specific files, is called a(n) __________ system.

A filing system in which materials can be located without consulting an intermediary source of reference is said to be a(n) __________ system.

A(n) __________ schedule is a plan for keeping and purging medical records.

Entities considered essential or necessary are called __________.

Any of a set of physical properties, the value of which determines characteristics or behavior, is called a(n) __________.

The type of record created by an entity that is a single organization involved in the patient's care is an electronic __________ record.

The type of record that is created from more than one healthcare organization and can be managed and consulted by licensed clinicians and staff from those organizations who are involved in the patient's care is an electronic __________ record.

The business care and prudence expected from a person seeking to satisfy a legal requirement under similar circumstances is called ________________.

Most experts agree that the EHR system will help reduce medical __________.

Additional training on the EHR system is needed to run it at full __________.

Perhaps the most difficult obstacle to overcome is the __________ of employees in physicians' offices who dislike change.

A process of electronic data entry of medical practitioner or provider instructions for the treatment of patients is called _______________.

The EHR billing system can perform online insurance __________ and can capture demographic data.

The EHR system's __________ component allows the physician's staff to communicate with and send claims electronically to insurance companies.

A storage method that connects to the back of the main computer and can be unplugged and taken out of the facility is an external __________.

The medical assistant must always listen to the patient's __________ about the EHR system.

The medical assistant should expect __________ from some patients, who may worry that their information is being put "out on the Internet."

A computer that functions as a(n) __________ at the medical facility is another form of EHR system backup.

The EHR system should be backed up __________.

Remember that all backup systems need __________ to run.

Meriting condemnation, responsibility, or blame especially as wrong or harmful is called __________.

The healthcare industry is one of constant __________, and the medical assistant is expected to stay abreast of current trends, laws, and requirements.

EHR systems must protect the patient's right to __________.

The patient owns the medical record.

An aggregate of activities designed to ensure adequate quality is called quality control.

Subjective information is that which the physician observes during the physical examination of the patient.

A standard, nationwide rule must be followed in establishing a records retention schedule.

The three basic filing methods are alphabetic, numeric, and alphanumeric.

Reverse chronologic order is where the most recent item is on the top and older items are filed farther back.

A provisional diagnosis is not a final diagnosis and usually is made before test results are received.

Medical records offer protection to the physician during legal proceedings if they are accurate and complete.

When documents are added to a patient's chart, the most recent information should be placed on top.

Outguides are heavy guides used to replace a folder that has been removed temporarily.

By legal definition, if it isn't charted, then it didn't happen.

Numeric filing provides extra confidentiality to medical records.

The computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages.

Color coding is used only for patients' records and not for business records.

HITECH Act stands for Health Information Technology for Economic and Clinical Health Act.

The patient's medical record should never leave the office.

The EMR relates to more than one healthcare organization.

The American Recovery and Reinvestment Act of 2009 is commonly known as the Economic Stimulus Package and was meant to promote economic recovery.

PHI stands for "private health information."

Usually, more staff members are needed when an office uses an EHR system.

Less storage space is needed for EHR systems.

Files still must be purged annually when an EHR system is used.

Because some physicians' handwriting is illegible, the electronic health record helps guarantee that the documents will be readable even several years after their creation.

Files still must be purged annually when an EHR system is used.

Information contained in an electronic health record usually can be accessed from several different physical places.

The EHR allows access to patient information in an emergency.

Very little statistical information can be gleaned from an EHR system.

An electronic health record system conceivably could hold all the patients seen over the life of a physician's practice.

Physicians can expect reductions in the amounts that they are paid from Medicare and Medicaid if they are not in compliance by 2015.

In Subtitle D of the HITECH Act, the privacy and security concerns related to the electronic submission of health information are addressed.

Both the physician and staff members must receive training in the use of the EHR system.

The software of an EHR system can be designed to be compatible with a medical specialty office, such as pediatrics or oncology.

The EHR system can allow patients to set their own appointments using the Internet.

Charge capture relates to charges for missed appointments.

The system is not capable of telling whether a certain procedure matches a specific diagnosis code.

Physicians performing consultations still must request paper records on a patient, even if both the referring physician and the consulting physician are using an EHR system.

Brochures are helpful for explaining a new EHR system to patients.

Match the EHR acronym with all the appropriate definitions. (Select all that apply.)

Match the EMR acronym with all the appropriate definitions. (Select all that apply.)

Match the PHR acronym with all the appropriate definitions. (Select all that apply.)