Question 1

Which statement is not true regarding the reasons for keeping accurate medical records?

Accepted Answer

A)   The medical record provides critical information for other caregivers.
B)   Effects of various treatments can be tracked and statistics gleaned from them.
C)   The patient's family may want to examine the records and correct errors.
D)   Accurate records are vital for financial reimbursements.E) C) and D)
F) None of the above

Question 2

The most frequently used follow-up method is a

Accepted Answer

A)   tickler file.
B)   transitory file.
C)   practice management file.
D)   None of the aboveE) None of the above
F) A) and B)

Question 3

Information that is gained by questioning the patient or that is taken from a form is called ________________ information.

Accepted Answer

A)   confidential
B)   subjective
C)   objective
D)   necessaryE) A) and B)
F) All of the above

Question 4

Many healthcare facilities now use voice recognition software for transcription. The system can be used to dictate which types of reports?

Accepted Answer

A)   Progress notes
B)   Letters
C)   E-mails
D)   All of the aboveE) A) and D)
F) All of the above

Question 5

Who ultimately decides whether a medical record can be released?

Accepted Answer

A)   The physician
B)   The office manager
C)   The medical assistant
D)   The patientE) A) and C)
F) A) and B)

Question 6

The __________ diagnosis is temporary and is made before test results have been received.

Accepted Answer

A)   differential
B)   provisional
C)   Both A and B
D)   None of the aboveE) A) and B)
F) A) and C)

Question 7

Using EHRs for e-prescribing and CPOE will meet the requirements of

Accepted Answer

A)   HIPAA.
B)   Affordable Care Act.
C)   meaningful use.
D)   OSHA.E) B) and C)
F) None of the above

Question 8

PHI stands for

Accepted Answer

A)   private health information.
B)   past health information.
C)   protected health information.
D)   None of the aboveE) A) and C)
F) B) and C)

Question 9

Information contained in an electronic health record usually can be accessed from several different physical places.

Accepted Answer

A) True 
 B)False

Question 10

Which of the following is not needed when describing a patient's chief complaint?

Accepted Answer

A)   Remedies the patient has tried to relieve symptoms
B)   The duration of pain
C)   The time when symptoms were first noticed
D)   How many family members are healthyE) A) and B)
F) A) and C)

Question 11

A(n)  __________ schedule is a plan for keeping and purging medical records.

Accepted Answer

A)   direct
B)   indirect
C)   progressive
D)   retentionE) B) and C)
F) B) and D)

Question 12

The patient portals can allow patients to set their own appointments using the internet.

Accepted Answer

A) True 
 B)False

Question 13

The medical assistant should consider which of the following when selecting filing equipment?

Accepted Answer

A)   Fire protection
B)   Cost of space and equipment
C)   Confidentiality requirements
D)   All of the aboveE) B) and C)
F) A) and B)

Question 14

Which of the following are common types of filing equipment found in a medical office?

Accepted Answer

A)   Rotary circular files
B)   Horizontal shelf files
C)   Automated files
D)   All of the aboveE) B) and C)
F) A) and D)

Question 15

The type of medical record organization that has the following four components; database, problem list, treatment plan, progress notes.

Accepted Answer

A)   Source-oriented
B)   Problem-oriented
C)   Alphabetic
D)   Reverse-chronologicE) All of the above
F) C) and D)

Question 16

HIPAA recommends that physicians keep the records on patients for at least

Accepted Answer

A)   1 year.
B)   2 years.
C)   3 years.
D)   HIPAA does not recommend a number of years.E) None of the above
F) A) and B)

Question 17

A filing system that uses a combination of letters and numbers is said to be __________.

Accepted Answer

A)   terminal digit
B)   numeric
C)   alphabetic
D)   alphanumericE) A) and B)
F) A) and C)

Question 18

An electronic record of health-related information that can be drawn from multiple sources and is managed, shared, and controlled by the individual is a

Accepted Answer

A)   EHR.
B)   EMR.
C)   PHR.
D)   None of the aboveE) B) and C)
F) All of the above

Question 19

A filing system that requires the use of alphabetic cross-reference to locate specific files is called a(n)  _____________ system.

Accepted Answer

A)   shelf filing
B)   indirect filing
C)   direct filing
D)   shinglingE) A) and B)
F) A) and C)

Question 20

Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to

Accepted Answer

A)   make frequent eye contact with the patient and smile.
B)   type in every word the patient says.
C)   make sure the patient is not hiding any part of the health history.
D)   sit in a chair across from the patient so that the person cannot see the screen.E) None of the above
F) A) and C)

Exam 19: The Health Record

Who ultimately decides whether a medical record can be released?

Correct AnswerverifiedShow Answer

A(n) __________ schedule is a plan for keeping and purging medical records.

Correct AnswerverifiedShow Answer

A filing system that uses a combination of letters and numbers is said to be __________.

Correct AnswerverifiedShow Answer

An electronic record of health-related information that can be drawn from multiple sources and is managed, shared, and controlled by the individual is a

Correct AnswerverifiedShow Answer

The __________ diagnosis is temporary and is made before test results have been received.

Correct AnswerverifiedShow Answer

Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to

Correct AnswerverifiedShow Answer

The most frequently used follow-up method is a

Correct AnswerverifiedShow Answer

Which of the following is not needed when describing a patient's chief complaint?

Correct AnswerverifiedShow Answer

Which statement is not true regarding the reasons for keeping accurate medical records?

Correct AnswerverifiedShow Answer

HIPAA recommends that physicians keep the records on patients for at least

Correct AnswerverifiedShow Answer

The patient portals can allow patients to set their own appointments using the internet.

Correct AnswerverifiedShow Answer

The medical assistant should consider which of the following when selecting filing equipment?

Correct AnswerverifiedShow Answer

Information that is gained by questioning the patient or that is taken from a form is called ________________ information.

Correct AnswerverifiedShow Answer

Information contained in an electronic health record usually can be accessed from several different physical places.

Correct AnswerverifiedShow Answer

A filing system that requires the use of alphabetic cross-reference to locate specific files is called a(n) _____________ system.

Correct AnswerverifiedShow Answer

Many healthcare facilities now use voice recognition software for transcription. The system can be used to dictate which types of reports?

Correct AnswerverifiedShow Answer

The type of medical record organization that has the following four components; database, problem list, treatment plan, progress notes.

Correct AnswerverifiedShow Answer

PHI stands for

Correct AnswerverifiedShow Answer

Using EHRs for e-prescribing and CPOE will meet the requirements of

Correct AnswerverifiedShow Answer

Which of the following are common types of filing equipment found in a medical office?

Correct AnswerverifiedShow Answer

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