Competency Challenge: Medical Records (Chapter 23 The Medical Record, Documentation, and Filing)

subject filling

requires tickler file to locate the identifier

alphabetic filling

uses the letters of patient's last name

numeric filing

Requires a tickler file to locate the identifier

terminal digit filing

Uses numbers that indicate shelves or drawers where the file is housed

Place the steps for correcting a medical record in the appropriate order.

Draw a line neatly through the incorrect entry

Write "Corr.", the date, and your initials in the margin of the page

Write or type the correct information either above or below the line

Step 1:Draw a line neatly through the incorrect entry

Step 3:Write "Corr.", the date, and your initials in the margin of the page

Step 2: Write or type the correct information either above or below the line

Which of the following is a purpose of the medical record? Select all that apply.

a. Maintains and documents the course of medical evaluations, treatments, and changes in condition

b. Used only for insurance purposes

c. Helpful in conducting research

d. Provides legal protection for both the patient and the provider

a. Maintains and documents the course of medical evaluations, treatments, and changes in condition

Helpful in conducting research

d. Provides legal protection for both the patient and the provider

Which rules apply when filing patient charts? Select all that apply.

a. When titles are used, they are considered as an indexing unit that follows.

b. Foreign language prefixes are indexed as separate units.

c. Names that include a single letter are placed before full names beginning with the same letter.

d. Names of individuals are assigned indexing units: last name, first name, middle, and succeeding names.

c. Names that include a single letter are placed before full names beginning with the same letter.

d. Names of individuals are assigned indexing units: last name, first name, middle, and succeeding names.

Match the element of the medical record with the appropriate description.

Patient information form: ...

Past, family, and social history: ...

Patient medical history: ...

1: includes a patient's demographic information

2: a patient's alcohol and tobacco usage

3: includes a patient's operations, accidents, or injuries

Which is subjective and which is objective?

Weight 152 lbs: ...

Distended abdomen: ...

Dizziness: ...

BP 152/88: ...

Ringing in the ears: ...

Headache: ...

1: objective

2: objective

3: subjective

4: objective

5: subjective

6: subjective

Which statement about the source-oriented medical record is correct?

a. Progress notes are generally documented in a paragraph format.

b. The records are not separated by subject matter.

c. This form of charting is easy to follow and track a specific patient problem.

d. Another section lists chronic problems, with dates of service for each problem.

a. Progress notes are generally documented in a paragraph format.

What is the purpose of an outguide? You can select all that apply.

a. provides a place to file material until the original folder is returned

b. separates current encounters from past encounters

c. temporarily replaces a folder that has been removed

d. makes refiling much easier and alerts the medical assistant to missing files

a. provides a place to file material until the original folder is returned

c. temporarily replaces a folder that has been removed

d. makes refiling much easier and alerts the medical assistant to missing files

Whether the patient's father and mother are living and well, age at death, and cause of death, are information found in...

a. family history.

b. present illness history.

c. social history.

d. past history.

a family history

What was the purpose of the HITECH Act?

a. to ensure the security of all electronic health information

b. to maintain the security of patient information while enabling providers to share critical information about patients

c. to promote the adoption and meaningful use of health information technology

d. interoperability and improving patient access to health information

c. to promote the adoption and meaningful use of health information technology

What law is violated if patient information is posted on social media?

a. HPIP

b. HIPAA

c. SOAP

d. HITECH

HIPAA