35 terms

Kinn's Chapter 14 Questions

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Terms in this set (...)

Subjective
Information that is gained by questioning the patient or that is taken from a form is called ________________ information.
Indirect
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.
a. shelf filing
placing a mark indicating where to file a particular item
Releasing a record, with regard to filing it, means:
Freeman, Jill M.D.
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?
Stilesduncan, Amanda M.
How would you properly index the name "Amanda M. Stiles-Duncan" for filing?
The physician or agency where services were provided
Who is the legal owner of the information stored in a patient's record?
medical attention that continues smoothly from one provider to another so that the patient receives the most benefit
Continuity of care means:
power of attorney
A legal instrument that authorizes a person to act as the agent of the grantor is called a:
Rotary circular files
Lateral files
Automated files
Which of the following are common types of filing equipment found in a medical office?
1. Patient charts can be found quickly.
2. It is easy to tell when a file has been misplaced.
3. Patient charts can be refiled quickly.
What are advantages of color-coded filing systems?
1. Accurate records are vital for financial reimbursements.
2. The medical record provides critical information for other caregivers.
3. Effects of various treatments can be tracked and statistics gleaned from them.
What are the reasons for keeping accurate medical records?
1. Progress notes
2. Diagnosis
3. Physical exam findings
Examples of objective information are
To protect the patient's health and well-being
What is the most important reason for telling the physician when a charting error is discovered later?
1. Insert the correction above or immediately after the error.
2. In the margin, initial and date the error correction.
3. Do not hide charting errors.
When correcting charting errors
1. Explain to the patient that the release form is necessary.
2. Review the record release form with the patient and ask ether the person understands it.
3. Have the patient sign the form in the space indicated.
4. Make a copy of the form for the patient's chart.
Steps for records release
written release from the patient
The medical record should be released only with a:
Until the minor reaches the age of majority, plus 3 years
Medical facilities should keep records on minors for how long?
1. It allows periodic expansion without shifting folders.
2. It provides additional confidentiality to the chart.
3. It saves time in record retrieval and refiling.
Advantages of numeric filing system
1. Risks and benefits of the procedure
2. Reasonable alternatives to the procedure
3. Risks and benefits of not performing the procedure
An informed consent form must address
1. Make sure the patient's name is spelled correctly
2. Review the forms the patient filled out for completeness
3. Copy the insurance card or make sure that insurance information is included
When preparing a file for a new patient, the medical assistant should:
OUTfolder
An item used to provide space for the temporary filing of materials is called a(n):
computer-based medical record
The most efficient type of medical record is the:
shingling
The method of filing in which one report is laid on top of the older report, resembling a roof, is called:
Closed
Files for patients who have died, moved away, or otherwise terminated their relationship with the physician are called _____________ files.
1. Fire protection
2. Cost of space and equipment
3. Confidentiality requirements
When selecting filing equipment
Purging
The process of moving an active file to inactive status is called:
physician or provider
The physical medical record belongs to the:
drawing a line through the entry and writing the correct information
A correction to a medical record can be made by:
1. Patient from another area who is only in the city for a short while
2. Letter requesting a reprint from a magazine
3. Letter requesting information about a product or drug
A temporary or transitory file might be used for a:
1. Individuals working at home
2. A business that offers transcription services
3. A hospital employee who does extra transcription work
Transcription tasks might be outsourced to:
The patient
Who ultimately decides whether a medical record can be released?
A. Martin
Which of the following names should be filed first:
A. Martin
Amy Martin
William Jones
Which of the following names should be filed first:
Wm. Jones
William Jones
MacAllister
Which of the following names should be filed first:
MacAllister
McAllister
A Roberts Production
Which of the following names should be filed first:
A Roberts Production
The Robertson Clinic