Today's Medical Assistant, Ch. 43 Medical Records Management

Which of the following are true about both paper medical records and electronic medical records?

They provide for continuity of care, they provide an ongoing record of the pt's state of health, they are legal documents if there is a question about the care given, they usually include information from more than one source (All the above)

What is used to hold the medical records if the medical office uses a paper medical record?

Vertical drawer file cabinets, Open-shelf filing units arranged horizontally, Shelf filing units with pull-down fronts, Lateral drawer file cabinets

Why are inactive records removed from the active file area in most offices?

To create more space for the records of new pt's

Which of the following types of medical records may be reviewed to record statistical information?

Both paper medical records and electronic medical records

What usually happens to the paper medical record after a medical office transitions to an electronic health record system?

Baseline data and recent information is scanned into the electronic record, and the paper record is kept available for two to three years

What is used to hold medical records if they are filed in an ordinary file cabinet?

Manila folders with one or more tabs on the side that opens

What is true about labels used on paper medical records?

Pressure-sensitive self-adhesive labels are usually used

What is always necessary if a paper medical system is used?

A means to lock the medical record storage cabinets or storage room

When is it recommended that file folders used to hold paper medical records be broken down into two folders?

When the width of the folder reaches 3/4 in

What is an outguide?

A stiff piece of paper or plastic that is placed in a file when a medical record is removed.

Which of the following is an indirect method of filing?

Numeric

What is an advantage of using color-coded labels or folders?

It reduces the risk of misfiling

If the office is using a color-coded system, who needs to know the meaning of the colors in use?

All office staff

In a paper medical record system, how are laboratory reports often filed if they are smaller than 9x12 inches?

Using mounting sheets, with the oldest report at the back on the bottom.

What is an indexing unit in alphabetic filing?

Each part of a patient's name

What is the first indexing unit in alphabetic filing?

Last name

What is the second indexing unit in alphabetic filing?

First name

If two pt's have exactly the same name, what information is used to put their medical records in order?

Street address

Which filing system used for paper medical records protects pt id most successfully?

Numeric

Using the alphabetic system of filing, what would "The Harris Office Supply Company" be filed under?

H

If the terminal digit filing system is used, what is the first filing unit for the number 01-68-72-59?

59

If the terminal digit filing system is used, which of the following medical record numbers comes first in the files?

72-81-19-02

Where should the MA's paper tickler files be stored?

In a desk or file cabinet near where the MA usually sits

What must occur before a piece of correspondence can be filed in a pt's paper medical record?

It must be initialed by the physician

In what order are documents filed into a section of the source-oriented medical record?

In reverse chronological order (most recent first)

What determines the classification of "inactive" for a medical record?

Office policy

How long should the medical records of minors be kept?

Until the patient reaches the age of majority plus the number of years for the statute of limitations in that particular state.

When can a physician destroy a pt's file?

When the record has been inactive at least seven years after the statue of limitations has expired

Which of the following is the least common method for backing up the electronic medical record?

External hard drive

What is a guideline for the storage of backup copies of electronic medical records?

If possible, they should be stored off site in a secure location

Which of the following makes it easier to find a paper medical record that has been removed from the files?

Filing out a card to place in the outguide for every record that was removed

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