MA Ch 8 Medical Records

Which of the following should be included in patient records?

• Incident reports involving the patient

• Records of family members also seen at the practice

• Consent forms, both general and for procedures/surgeries

• Notes detailing staff members’ honest opinions about the patient.

Why should an MA who works at a facility with electronic records also understand how to work with paper records?

• Because facilities often shift from electronic to paper records if they find the software difficult to work with

• Because understanding paper records is a good form of intellectual exercise

• Because in some situations paper records may still be used alongside electronic records

• Because paper records are better for preventing errors.

Which of the following may be a disadvantage of paper records?

• They are difficult to read.

• They require a lot of storage space.

• They are expensive to maintain.

• Patients do not trust them.

A (a)   medical record is arranged according to the patient’s treatments or diagnoses.

• Personal

• Electronic

• Source-oriented

• Problem-oriented

Patient portals may be available

• In paper form

• As smartphone apps

• Only for certain patients in a practice

• For an additional fee

What must be true of a facility’s backup system for electronic health records?

• It must be on paper and stored in a locked area of the facility.

• It must be HIPAA-compliant.

• It must be accessible to patients.

• It must be cloud-based.

In relation to electronic health records, what does a firewall do?

• Prevents unauthorized access

• Allows patient access.

CMS suggests that paper medical records be kept for a minimum of (a)   after the record is closed.

• 1 year

• 5 years

• 10 years

• 15 years

How are electronic records destroyed?

• By hitting a delete button in the EHR software

• By dragging that patient’s file to a trash can icon on the screen

• By restoring the EHR software to default settings

• By magnetic degaussing.

Which of the following is true of PHI and a patient’s insurance company?

• The patient must authorize the release of PHI to the insurance company.

• Insurance companies do not need access to PHI to process claims.

• Insurance companies may receive a patient’s PHI without the patient’s knowledge or permission.

• Insurance companies contact the patient directly to request any necessary PHI.