Chapter 3: Office Administration Practice Questions

Can original documents leave the medical facility from where it was created? Are patients able to access their medical records?

No - original documents must remain in the hands of the medical facility where it was created; Yes - patients are able to request and have access to their medical records

What are some points to remember regarding paper-based records?

1. Must be written legible and grammatically correct

2. Should be located in an area that is easy to access

3. While many places are transitioning into electronic-based records, some medical facilities continue to use paper-based records

Can you name the different methods of charting - electronic and paper based? How are each one different? Be able to explain the advantages and limitations of each method of charting!

Paper-based: source oriented, SOAP, POMR

Electronic-based: EHR and EMR

Source oriented is easy to read the care provided by healthcare providers. It can take time and lead to fragmented care.

SOAP allows the patient's health problems to be in the front of the chart, therefore more care-focused. It can be taxing to consistently be up to date on patient's problems and can lead practitioners to be too narrowly focused on problems

POMR presents logical formatting and allow collaboration among healthcare providers. It needs alot of note taking and can be seen as inefficient.

Why is storing and filing patient medical records significant? Be able to know the steps and methods to store and file patient medical records!

Patient records contain information about the patient that must be kept confidential and potentially will be needed in the future by health insurance companies, other healthcare providers/institutions, and the patient.

Steps include:

1. Conditioning

2. Releasing

3. Indexing and Coding

4. Sorting and Filing

Methods to store and file are:

- Color coding

- Alphabetical

- Numerical

- Subject

- Terminal Digit

When obtaining patient information, can you name what information is needed from the patient's demographic and medical history?

Demographic: name, gender, date of birth, marital status, occupation, employer, home address, telephone

Medical and Social History: current/past illness, surgical procedures, medications, injuries, daily health habits, family/hereditary medical history, use of tobacco, alcohol, and drugs

Is a patient's social security number required to be listed on a patient information sheet?

It is no longer needed to obtain a patient's SSN

Be able to explain informed consent! Who is able to explain procedures and questions involving a patient's informed consent?

Informed consent is process of documentation where the patient is willing to participate in a treatment plan, after being aware of the procedure along with the risks and benefits, in addition to alternatives of a procedure and its respective risks and benefits. Patients will also have the time to ask any questions or concerns before informed consent is obtained.

Physicians are allowed to explain procedures and questions involving a patient's informed consent; Medical assistants cannot do this task!

Name the advantages and limitations of using an appointment book or a computer to schedule appointments and name the methods of scheduling a medical facility that can apply their practice.

Appointment books are good to use when electricity or power is not available. A medical space will need to provide space for the book along with space to write down important information. In addition, only one person at a time can have access to the book.

Computers are good to use when more than one person wants to have access at the same time. In addition, all information can be structured within the system. Without electricity/power, computer cannot be used for scheduling appointments.

Methods and strategies to schedule include: open office scheduling, advanced bookings which include wave scheduling, cluster scheduling, and self scheduling

Be familiar with the general process of in-patient versus outpatient admissions.

For in-patient admissions and schedules:

An order must be provided by a physician, insurance will then be verified and the appointment will be set. When reaching out to the medical facility, information such as demographics, ordering any necessary tests, special instructions, etc. will be needed regarding the patient. Afterwards, the patient will be contacted to inform about admission details, including but not limited to the date, time, location, any special instructions, and education on pre-admission testing.

For outpatient admissions and schedules:

A physician must order diagnostic testing while the patient's insurance will be checked to be valid as well looking into the availability of both the patient, medical facility, and physician. When reaching out to the medical facility, information such as demographics will be needed regarding the patient along with ensuring the medical facility can schedule the tests and procedure needed for the patient. Afterwards, the patient will need to be contacted to inform about admission details, including but not limited to the date, time, location, any special instructions, and education on pre-admission testing.

What is HIPAA and how does it relate to insurance?

HIPAA stands for the Health Information Portability and Accountability Act

For insurance companies, HIPPA allows access to information such as demographics, treatment/surgery plans, and other necessary medical information for payment and coverage purposes.

Can a patient refuse treatment? Under what conditions can minor patients refuse treatment on their own?

Yes - a patient can refuse treatments. Patients who are minors can refuse treatment under these conditions:

1. Minors who are at least 12 years old who visit related to substance abuse/care or pregnancy

2. Minors who are at least 12 years old who visit related to suspected physical and sexual abuse

3. Emancipated minors

What are some obligations physicians must do besides meeting and treating patients? What can a medical assistant do to assist a physician in travel arrangements?

Besides meeting with patients, doctors have to take time reading e-mails, making phone calls, attending conferences and conventions, hurry to attend emergency issue, etc.

First, medical assistants should be familiar with how a physician would like their schedule arranged before taking action on their behalf. For travel arrangements, it is critical to know and check the duration of the trip (arrival and departure times) along with the budget and preferences the physician has when booking tickets, hotels, etc.

What responsibilities may a medical assistant have in regards to opening and closing a medical facility?

For opening:

- turning off alarm systems

- turning lights on

- examining the medical facility

- preparing and stocking rooms with necessary supplies for patient visits

For closing:

- securing computers and file cabinets

- setting alarms

- preparing lab specimens to be stored, processed, shipped, etc.

- general housekeeping

Who is responsible for ensuring a physician's DEA number is not expired? What are some certifications that need to be active for employees for HR documentation purposes?

The medical assistant will be responsible for ensuring a physician's DEA number is active. Certifications that need to be audited and active include CPR, CEU, MA, BLS, and many more that are needed in order to work.

How often should inventory be checked? Be able to name things that are considered non-durable and durable! In regards to controlled substances, inventory reports should be sent to whom? When would police officers get involved in inventory?

Inventory should be checked periodically.

Non-durable items include paper, pens, staples, syringes, needles, and band-aids (usually non-expensive and replaceable items). Durable items include, the EKG machine, computers, fax machine, otoscope, and spirometers (usually expensive and difficult to replace).

Inventory reports related to controlled substances should be provided every 2 years.

Police officers would get involved if controlled substances from the inventory were stolen.