No matter the reason for the requested records, a patient must provide a signed authorization before any information may be released. The authorization must specifically indicate who should receive the information and for what purpose it will be used. Which type of records/results require additional authorization in addition to a general release of information before the information may be release
Mental health records
You often hear the terms EMR and EHR used interchangeably, but there is a distinction. Electronic health records (EHR) refer to which of the following
The interoperability of electronic medical records. Or the ability to share medical records with other health care facilities.
Information supplied by the patient, including routine information about the patient, past personal and medical history, family history, and chief complaint is known as ______ information
Subjective
Information the provider and various members of the health care team provide (e.g., vital signs, exam findings, diagnostic tests, and so on) is known as _______ information
Objective
One of the most frequently used data collection methods for patient visits is the SOAP note. What does the acronym SOAP stand for?
SUBJECTIVE, OBJECTIVE,ASSESSMENT, PLAN
Another method for charting that encourages providers to include greater detail of the information obtained during the interview and examination is known by the acronym CHEDDAR. The "Ds" in CHEDDAR refer to which of the following?
Where results of additional testing and a comprehensive list of all medications may be placed
Folders or cards are easily filed alphabetically or numerically, but the procedure for filing reports and letters requires several steps. What is the first step in filing?
Inspecting
What type of filing refers to filing according to date?
Chronologic
HIPAA requires all medical records, signed consent forms, authorization forms, and any other HIPAA-related documents to be retained for ______ years
SIX
Records of deceased patients must be maintained for ____ years
TWO
The first indexing unit of a coded unit should be ___________ to assure proper filing.
Underlined
A patient's ethnicity is included in which part of a patient's medical record?
Demographics
What is the purpose of the Medicare PI Program
To promote interoperability
The S in SOAP stands for:
Subjective
Which of the following triggers a mandatory release of the medical record?
In the case of infectious diseases
How many objectives are there in the Medicare Promoting Interoperability program scoring methodology?
Four
Which of the following statements best describes the indexing rules accurately?
Requires you to make a decision about the name, subject, or other identifier
What was the intent of the HITECH Act?
Promoting the adoption and meaningful use of health information technology
Regarding storing medical records, which is true?
Records may be purged on a regular basis to make room for new charts.
Which of the following is the proper way to make a correction to a progress note entry?
Use edit/ addendum in an electronic record
Which of the following is the most common method for filing paper records in the medical office?
Alphabetically
Uses number that indicate shelves or drawers where the file is housed
Terminal digit filing
Uses the letters of patients last name
Alphabetic filing
Uses business information
Subject filing
Requires tickler file to locate the identifier
Numeric filing
Which of the following is a purpose of the medical record? Select all that apply.
Helpful in conducting research, Maintains and documents the course of medical evaluations, treatments, and changes in condition, Provides legal protection for both the patient and the provider
Which rules apply when filing patient charts? Select all that apply.
Names of individuals are assigned indexing units: last name, first name, middle, and succeeding names, Names that include a single letter are placed before full names beginning with the same letter.
includes a patient's demographic information
patient information form
Includes a patient's alcohol and tobacco usage.
past, family, and social history
Includes a patient's operations, accidents, or injuries
Patient medical history
Which statement about the source-oriented medical record is correct?
Progress notes are generally documented in a paragraph format.
What is the purpose of an out guide? Select all that apply.
provides a place to file material until the original folder is returned, makes refiling much easier and alerts the medical assistant to missing files, temporarily replaces a folder that has been removed
Whether the patient’s father and mother are living and well, age at death, and cause of death, are information found in.
Family history
What was the purpose of the HITECH Act?
to promote the adoption and meaningful use of health information technology
What law is violated if patient information is posted on social media?
HIPPA
What is one of the most widely used methods of charting, appropriate for most types of patient encounters?
SOAP note
What type of progress note is organized and entered based on where medical documentation came from, whether from a provider, laboratory, or other source?
POMR note
What area of HIPAA pertains primarily to records management?
Ensuring the security of all electronic health information
In the event of an audit, the Centers for Medicare & Medicaid Services (CMS) will ask for documentation to evaluate how that office is complying with the security standards of the Security Rule. Which of the following is part of that evaluation?
Administrative safeguards
Having policies and procedures in place that identify and protect reasonably anticipated threats to the security or integrity of the information and to protect against reasonably anticipated, impermissible uses or disclosures, applies to compliance within which HIPAA rule?
Security rule
Since 2004, when then President George W. Bush addressed the American Association of Community Colleges and commented that the United States was behind the times regarding patients’ records, the federal government has provided incentives for medical practices to convert to electronic health records. These measures are now known as the Medicare Promoting Interoperability Program. To qualify for these incentives, providers must satisfy _______ performance measures
meaningful use
in all medical practices, the shelves holding the paper charts and files become full at some point, and there is no room for any more charts. Periodically the files of those patients who are no longer being seen by the provider(s) will be:
purged
In all types of filing systems, the first step in filing letters and reports into paper medical records is to:
inspect
Use of a geographic filing system is useful in:
The community health environment
Which is the third step in filing, and is done by marking the index identifier on the papers to be filed?
Coding
HIPAA regulations and recommendations require a designated __________ who must keep track of who has access to protected health information within a facility.
Privacy officer
The focus of the ___________ applies to paper records but is primarily concerned with electronic information and methods to protect it from invasion, accidental disclosure, or loss.
HIPAA security rule
The purpose of the Medicare Promoting Interoperability Program is not only to institute the adoption of EHRs, but to ascertain that practices use their EHR software in what way?
to its fullest
Who does the patient's chart legally belong to?
The provider or practice
Who ultimately governs minimum requirements for records retention?
HIPAA