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Get faster at matching terms Terms in this set (92)A correction to a medical record can be made by drawing a line through the entry and writing the correct information Advantages of the EHR system include ability of the physician to see more patients in a day 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. indirect filing An aggregate of activities designed to ensure adequate quality is called quality control.
True An electronic health record system conceivably could hold all the patients seen over the life of a physician's practice. True A provisional diagnosis is not a final diagnosis and usually is made before test results are received. True A set of physical properties, the values of which determine characteristics or behavior, is called parameters A standard, nationwide rule must be followed in establishing a records retention schedule. False A strong, highly glazed composition paper or heavy card stock is called pressboard
Because some physicians' handwriting is illegible, the electronic health record helps guarantee that the documents will be readable even several years after their creation. True Both the physician and staff members must receive training in the use of the EHR system. True Brochures are helpful for explaining a new EHR system to patients. True By legal definition, if it isn't charted, then it didn't happen. True Charge capture relates to charges for missed appointments. False Color coding is used only for patients' records and not for business records. False Continuity of care means medical attention that continues smoothly from one provider to another so that the patient receives the most benefit. Disadvantages of the EHR system include all of the above Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files. closed Files still must be purged annually when an EHR system is used. False 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. Both statements are true. HIPAA recommends that physicians keep the records on patients for at least HIPAA does not recommend a number of years. HITECH Act stands for Health Information Technology for Economic and Clinical Health Act. True How are corrections made to the electronic health record? A new entry or addendum must be added close to the original entry with the correct information and then initialed. How can the EHR function to best help improve a facility's appointment show rate? The system can be programmed to initiate reminder and confirmation calls to patients. How would you properly index the name "Amanda M. Stiles-Duncan" for filing? Stilesduncan, Amanda M. 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? Freeman, Jill M.D. Improved outcomes is part of which of the stages of meaningful use? Stage 3 In a paper record, which of the following is never an acceptable method of correction to a handwritten entry? Erase or use a correction fluid.
Information contained in an electronic health record usually can be accessed from several different physical places. True Information that is gained by questioning the patient or that is taken from a form is called ________________ information. subjective In most cases, does the electronic health record system require more or less storage space than a paper filing system? Less In Subtitle D of the HITECH Act, the privacy and security concerns related to the electronic submission of health information are addressed. True Less storage space is needed for EHR systems. True
Many healthcare facilities now use voice recognition software for transcription. The system can be used to dictate which types of reports? All of the above Match the EHR acronym with all the appropriate definitions. (Select all that apply.) Created and managed by authorized clinicians and staff from more than one healthcare organization Match the EMR acronym with all the appropriate definitions. (Select all that apply.) Electronic record of health-related information Match the PHR acronym with all the appropriate definitions. (Select all that apply.) Conforms to nationally recognized interoperability standards Medical assistants can encourage other staff members during a conversion to an electronic health record system by All of the above Medical facilities should keep records on minors for how long? Until the minor reaches the age of majority, plus 3 years Medical records offer protection to the physician during legal proceedings if they are accurate and complete. True Numeric filing provides extra confidentiality to medical records. True Outguides are heavy guides used to replace a folder that has been removed temporarily. True Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to make frequent eye contact with the patient and smile. PHI stands for "private health information." False Physicians can expect reductions in the amounts that they are paid from Medicare and Medicaid if they are not in compliance by 2015. True 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. False Reverse chronologic order is where the most recent item is on the top and older items are filed farther back. True Subjective information is that which the physician observes during the physical examination of the patient. False The "E" entry in the SOAPER charting method means education. The "R" entry in the SOAPER charting method means response. The advantages of using the color-coding filing system are the following: you
can use either the alphabetic or numeric color-coding system. The American Recovery and Reinvestment Act of 2009 is commonly known as the Economic Stimulus Package and was meant to promote economic recovery. True The computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages. False The EHR allows access to patient information in an emergency. True The EHR system can allow patients to set their own appointments using the Internet. True The EMR relates to more than one healthcare organization. False The medical assistant should consider which of the following when selecting filing equipment? All of the above The medical record should be released only with a written release from the patient The most frequently used follow-up method is a tickler file The newest component used today to complete transcription and authenticate records is __________ software. voice recognition The patient's medical record should never leave the office. True The patient owns the medical record false The physical medical record belongs to the Physician or provider The preferred filing method for a physician's office is the one most preferred by the staff. The process of moving an active file to inactive status is called purging The software of an EHR system can be designed to be compatible with a medical specialty office, such as pediatrics or oncology. True The system is not capable of telling whether a certain procedure matches a specific diagnosis code.
False The three basic filing methods are alphabetic, numeric, and alphanumeric. True 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) EMR. 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) EHR. Usually, more staff members are needed when an office uses an EHR system. False Very little statistical information can be gleaned from an EHR system. False What is one of the benefits of using a paper health record? Good evidence of patient care What is the HIPAA privacy rule requirement for the retention of health records? HIPAA does not include requirements. What is the most important reason for telling the physician when a charting error is discovered later? To protect the patient's health and well-being When documents are added to a patient's chart, the most recent information should be placed on top. True Which EHR system backup is probably the least trouble and requires the least amount of hardware? Online backup system Which of the following are common types of filing equipment found in a medical office? All of the above Which of the following functions of an electronic record can store lists of billing codes and current procedural terminology? Charge capture Which of the following health information exchanges allows providers to find and/or request information on a patient from other providers? Query-based exchange Which of the following indirect filing systems is used by a majority of large clinics and hospitals? Numeric filing Which of the following is not a method of organizing a medical record? Progressively Which of the following is not an advantage of a numeric filing system? Filing activity is greatest when the system is initiated. Which of the following is not an advantage of color-coded filing systems? All of the above are advantages. Which of the following is not needed when describing a patient's chief complaint? How many family members are healthy Which of the following is not objective information? Family history Which section of the law, commonly known as the Economic Stimulus Package, pertains to healthcare? HITECH Act Which statement is not accurate about correcting charting errors? Draw two clear lines through the error. Which statement is not true regarding the reasons for keeping accurate medical records? The patient's family may want to examine the records and correct errors. Who is responsible for calming patients' fears and concerns about switching to an electronic medical record system? The entire team at the office Who is the legal owner of the information stored in a patient's record? The physician or agency where services were provided Who ultimately decides whether a medical record can be released? The patient Sets found in the same folderMedical billing and coding week 2 test107 terms melissabeth2 Medical Insurance Chapter 445 terms SMS0619 Medical Coding II (Chapter 11/TEST REVIEW)47 terms tamhamm8 Ch. 2 Compliance, Privacy, Fraud, and Abuse in Ins…23 terms
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Which method is most commonly used to identify patients?Patient identifier options include:
Name. Assigned identification number (e.g., medical record number) Date of birth. Phone number.
What are the three basic filing methods?Filing and classification systems fall into three main types: alphabetical, numeric and alphanumeric. Each of these types of filing systems has advantages and disadvantages, depending on the information being filed and classified. In addition, you can separate each type of filing system into subgroups.
What is the name of the process that is used for maintaining order in files by separating active patient files from inactive patient files?Maintaining order in files by separating active from inactive files is: Purging. A system used as a reminder of action to be taken on a certain date is called: Tickler file or reminder note.
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What is name is given to the filing method where the most recent item pertaining to a patient is on the top and older items are filed farther back?
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