CEHRS Chapter 1 (book)

Which of the following is NOT found in the patient medical record?

• Immunization records

• Living will

• Operative reports

• Patient statement

An example of a HIPAA form that is included in the medical record would be:

• a patient information sheet

• a living will

• a Notice of Privacy Practices acknowledgement

• informed consent forms

An individual who is responsible for recording data in the patient record is called a:

• transcriber

• health records clerk

• data entry clerk

• documenter

Which of the following is NOT a documenter of the patient chart?

• Provider

• Patient

• Medical assistant

• Medical billing specialist

When accompanying a patient into the exam room, the MA commonly documents the:

• plan of treatment

• reason for no show

• chief complaint

• patient billing information

Practice management software:

• may be included as part of an interoperable EHR

• includes administrative functions like appointment books and billing

• must be purchased separate from the clinical EHR

• may be included as part of an interoperable EHR AND includes administrative functions like appointment books and billing

The receptionist would commonly document:

• patient vital signs

• patient no-shows

• diagnosis of the patient condition

• results of tests performed

Owner of the physical medical record:

• is always the provider

• is always the patient

• is the hospital the provider admits to

• is the one who creates and maintains the record

Which of the following professional organizations is made up of health information management professionals?

• AMA

• AAPC

• AAMA

• AHIMA

Which of the following professional organizations has identified the use of computers and electronic equipment in the medical office as one of its key competencies?

• AMA

• AAPC

• AAMA

• AHIMA