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43 terms

Medical Records Theory Review

STUDY
PLAY
T/F: Progressively is a method of organizing a medical record
False
What is the name of the type of info that is gained by questioning the patient?
Subjective
T/F: When taking a patient's cheif complaint you should ask how many family members are healthy?
False
T/F: Releasing a record, with regard to filing it, means: placing a mark indicating the item is ready to be filed
True
What is the proper way to index the name Amanda M. Stile-Duncan
StileDuncan, Amanda M
Who is the legal owner of the info stored in a patients record?
The Physician or facility "Maker"
Care which continues smoothly from one provider to another so that the patient receives the most benefit is called?
Continuity of Care
What is the name of the legal instrument authorizing one to act as the agent of the guarantor?
Power of Attorney
T/F: Family history is objective info?
False
What is the most important reason to tell the physician when there is an error in charting that is discovered later?
could effect the wellbeing of the patient
T/F: Draw 2 clear lines through an error in a patient medical record
false
What is the name of the filing system where an intermediary source of reference such as a file card is used to locate specific files?
Indirect Filing
What is the proper way to index the name Jill Freeman, MD.
Freeman, Jill (MD)
Name three types of filing equipment found in the medical record office
Rotary, lateral and automated
Name three advantages of color coded filing system:
misfiled chart is easily found
refile quickly
faster way of finding the patient
When is the only time a patients medical record can be released?
when a patient signs a consent form expressed permission
how long should you keep records on file for minors?
until they are 18yrs old and 3 years after
What 3 things must be addressed on an informed consent form?
Nature of procedure of treatment
risks/ benefits of the procedure of treatment
any reasonable alternatives to the procedure or treatment
risks of not performing procedure
what are the 3 stages of machine transcription?
dictating into adication unit
listening to what has been dictated
keyboarding
name 3 things that the medical assistant should do when preparing a file for a new patient:
name spell correct
all forms completed
get copy of insurance card
what is the name of the item used to provide space for temporary filing of materials?
out guide or out folder
what is the most efficient type of medical record?
computer based
what is the name of the method of filing where by 1 report is laid on top of an older report resembeling a roof?
shingled
what kind of files are filed for patients who have died, moved away or otherwise terminated their relationship with the physician?
closed files
what is the length of time recommended by HIPAA for a physician to keep medical records on patients that have died?
2yrs
what things should you consider when selecting filing equipment?
space cost fire protection and confidentiality
what is the name of the strong highly glazed compostion paper or heavy card stock?
pressboard
T/F Authenticated is a characteristic of high quality health data?
false
quality assurance is concerned with.....,...... and ....... of medical service
overuse, underuse and misuse
are mammograms for at risk patients overused or underused?
underused
where would you aquire a nosocomial infection?
hospital
NCHS keeps stats on
communicable diseases teen preg, common health HIV
Total power failure in a hospital would be considered a .......event
Sentinal event
what is the characteristic of high quality data that assures multiple users can obtain the data at one time?
accessibility
what year did HIPAA become effective?
2003
what is the name of the non profit organization that assists health care facilities by providing accrediations service?
JACHO
T/F: Exceeding standards and provides optimal healthcare to patient is in the interest most health care facilities now
true
T/F institute training on the job is one of demmings 14 poionts for management
true
t/f: Collection integrating and analyzing are tasks that health professionals perform data
true
what is te name of the organization that supports health info personal
AHIMA
hipaa places great restricitions on patients info for used for..... ..... purposes of .....
marketing soliciation and sales
what is the high quality data characterisitics that suggests that info in the database about a patient can be trusted
reliability
t/f: a pharmacy is allowed to offer patietns info to another entity that intern uses the info to solicit sale of related product to the patient
flase