MA Medical Records

Permission granted by an individual voluntarily and in his right mind is known as

a. consent

b. compliance

c. standard of care

d. duty of care

a. consent

A medical office assistants family asks to see the medical information of her brother-in-law who has just been brought into the emergency room. If the medical office assistant accesses the information it is

a. appropriate because she is a family member

b. violation of the Privacy Rule

c. permissible because she is an employee

d. prosecutable as fraud

b. violation of the Privacy Rule

Which of the following is the role of a medical transcriptionist in the health care setting?

a. converting paper-based records into electronic medical records

b. retrieving information from medical records

c. transforming medical information into a permanent document

d. editing electronic medical records

c. transforming medical information into a permanent document

Which of the following is a characteristic of an EMR system used by a medical office?

a. it is the principal medical record used in healthcare facilities

b. it incorporates computer system from many different vendors

c. it requires clinicians to use a interface to view date from different systems

d. it must be accessible to any specialists who are also treating the patiient

a. it is the principal medical record used in healthcare facilites

In which of the following medical record categories should the medical office assistant file a patients electrocardiogram result?

a. therapeutic service documents

b. diagnostic procedure documents

c. laboratory documents

d. encounter documents

b. diagnostic procedure documents

Which of the following medical reports includes patient demographic information, dates of hospitalization, reason for hospitalization, brief history, significant findings form examinations and tests, course of treatment, final condition of the patient, and final diagnosis?

a. discharge summary report

b. pathology report

c. history and physical report

d. operative report

a. discharge summary report

A patient with Medicaid presents to the providers office requesting copies of medical records. The patient presents a valid ID and signs a conest form and the medical office assistant charges the patient $10.00 for the copies. Which of the following is true regarding this charge?

a. a provider cannot charge any patient for medical records

b. a provider can charge for the medical records because the records belong to the provider

c. a provider cannot charge a Medicaid patient for medical records

d. a provider can charge for medical records if record reproduction is covered under the patients insurance

b. a provider can charge for the medical records because the records belong to the provider

A patient presents to the outpatient department for a chest x-ray and sputum culture. The patient was referred from his primary care physician from a long-term cough. The resident physician provides the inital interpretation of the x-ray fil and states "pneumonia" and signs the report. Seven days later the sputum culture indicates a streptococcal infection. Which of the following action shsould the medical office assistant take?

a. have the resident physician sign the original note and make an internal charge within the medical record

b. create a new medical narrative that would take the place of the original, along with an addendum

c. allow the note to stand because documentation countinuity allows for effective treatment of the patient

d. create an addendum because the new information must be connected to the orginial note.

d. create an addemdum because the new information must be connected to the orginial note

The medical assistant is contacting a patient to request they make a follow-up appointment. Which of the following forms should the medical assistant verify prior to leaving this message on the patients voicemail?

a. Consent to Treat

b. HIPPA Confidentiality and Privacy

c. Assignment of Benefits

d. Durable Power of Attorney for Healthcare

b. HIPPA Confidentiality and Privacy

Which federal regulation requires medical professionals to protect the privacy and confidentiality of patients health information?

a. OSHA

b. CLIA

c. CMS

d. HIPPA

d. HIPPA

In 1996, Congress passed which of the following statutor laws to ensure that patient information and records will be kept confidential?

a. ADA (Americans with Disabilities Act)

b. PPACA (Patient Protection and Affordable Care Act)

c. HIPPA (Health Insurance Portability and Accountability Act)

d. FMLA (Family and Medical Leave Act)

c. HIPPA (Health Insurance Portability and Accountability Act)

A patient calls the office asking for ECG test results. The individual answering the phone should

a. verify the patients first and last name before giving the patient results

b. verify the patients first and last name, date of birth, and social security number before giving results

c. let the patient know that the results cannot be discussed over the phone

d. make an appointment for the patients to meet with the ECG technician to discuss results

c. let the patient know that the results cannot be discussed over the phone

A phlebotomists failure to keep any or all privileged medical information private is called

a. breach of confidentiality

b. negligence

c. res ipsa loquitur

d. invasion of privacy

a. breach of confidentiality

A patient blood work came back with a diagnosis of an infection. Which finding would also be seen on the patients results?

a. leukocytes

b. erythrocytes

c. thrombocytes

d. platelets

a. leukocytes

It is necessary for an medical office assistant to copy/scan pricture identification and obtain required signatures

a. to bill the insurance company

b. to comply with HIPAA regulations

c. to confirm and protect the patients rights

d. to ensure and verify proper documentation

d. to ensure and verify proper documentation

The patient who refuses to pay their medical bill at the estabilshed rate after receiving health care services is in breach of which of the following?

a. HIPPA

b. contract

c. security

d. Patients Bill of Rights

b. contract

Which of the following regulates the time frame allowed for filing a lawsuit?

a. standard of proof

b. statute of limitations

c. arbitration

d. mediation

b. statute of limitations

An adolescent who has been legally granted the status of adulthood and no longer under the care of a parent or guardian is know as which of the following?

a. emancipated minor

b. age of majority

c. ward of the state

d. guardian ad litem

a. emancipated minor

The Needlestick Safety and Prevention Act exists to protect healthcare workers from accidental exposure to

a. carcinogens

b. blood borne pathogens

c. hazardous chemicals

d. biologic toxins

b. blood borne pathogens

Which of the following protects a volunteer from liability when providing emergency care in a non-healthcare setting?

a. Patients Bill of Rights

b. Good Samaritan Act

c. Code of Federal Regulations

d. Patient Self-Determination Act

b. Good Samaritan Act

The mutual recognition of a license from one state to another is known as which of the following?

a. informed consent

b. reciprocity

c. revocation

d. implied consent

b. reciprocity

The physician has a public duty to fulfill state reporting requirements in which of the following circumstances involving a patient? (select the 4 correct answers

a. dealth

b. stab wound

c. sexually transmitted infection

d. schedule V controlled substance abuse

e. elder abuse

a, b, c, d - dealth, stab would, sexually transmitted infection, elder abuse

Purging is the act of

a. moving a file from active to inactive

b. moving a file to storage

c. shredding a file

d. scanning a file into EHR

a. moving a file from active to inactive