WorksheetsMedical Records
Total questions: 44
Worksheet time: 23mins
Which of the following is the best description of a problem-oriented medical record?
Items of the same source are filed together
Items of the same severity are filed together
Items of the same medical condition are filed together
Items of the same insurance carrier are filed together
What must be true of all electronic medical records?
They must be accessed by physicians only.
They must be password-protected.
They must have a back-up paper record.
A patient, Patrick, claims that he received a treatment from Westerville Medical Center last month. However, the treatment is not recorded in his medical record. Which of the following is true according to the law?
The patient is always right.
The medical record must be updated immediately.
The treatment did not occur.
The patient is a liar and may be prosecuted.
What do patients have the right to do to their medical records?
Obtain copies
Request corrections to inaccurate information
All of the above
View them
Which of the following is NOT a part of a medical record?
Insurance information
Doctor's credentials
Correspondence
Demographic data
Which of the following is true about medical records?
They provide a written account of a patient's health care.
They provide a limited picture of a patient's health history.
They are not important to health care.
Which of the following laws provides guidelines for using electronic medical records?
HIPAA Simplification of Administration Rules
HIPAA Insurance Portability Rules
HIPAA Privacy Rule
HIPAA Security Rule
A benefit of using source-oriented medical records is that specific items can be found quickly.
True
False
Which of the following is an advantage of electronic medical records?
They are quickly available in emergencies.
They are legible and organized.
They do not require much storage space.
They allow multiple users to view files.
all of the above
Which of the following is an advantage of using paper medical records?
They require a lot of storage space.
They are easily misplaced.
They are complicated and hard to understand.
They are easy to keep confidential.
What should be at the front of a problem-oriented medical record?
Demographic information
Insurance information
An information sheet
A signed release form
Which of the following is NOT a feature of most EMRs?
Immediate access to patient records
Record medications and send information to the pharmacy
Create and print customized forms
Filing of physical folders
A patient's medical information can be released to anyone as long as the physician gives written permission.
True
False
What does EMR stand for?
Electrical management of records
Equipment for maintaining records
Elementary methodical recording
Electronic medical records
If a medical record is torn, what should the office assistant do before filing it?
Tape it to keep the item in good condition.
Staple it to keep the item in one piece.
Nothing, because medical records should not be altered.
What is the purpose of color-coding medical records?
To make files visible to patients
To eliminate the need for numeric and alphabetical filing
To create a more attractive office environment
To make filing easier and more efficient
Which step in the filing procedure involves putting items in order alphabetically or numerically?
Inspecting
Coding
Sorting
Storing
Indexing
Within a medical record, how are most records stored?
Numerically
Alphabetically
Chronologically
Reverse-chronologically
Which of the following is an appropriate method of coding in the filing procedure?
Highlighting the name
Circling the name
Writing the name in the form's upper-right corner
All of the above
What is used to label a section of folders on a shelf of medical files?
Markers
File labels
Out-guides
Guides
How are straight numerical medical records filed?
In alphabetical order by the patient's last name
In consecutive order by file number
In descending order by file number
Lisa R. Taylor recently got married and changed her name to Lisa R. Davis. For her medical records, how should the primary file be labeled?
Davis, Lisa R. SEE Davis, Lisa R.
Davis, Lisa R.
Davis, Lisa R. SEE Taylor, Lisa R.
Taylor, Lisa R.
How would you index and code the name Amelia Lynn Bogart?
Amelia Lynn Bogart
Amelia, Lynn, Bogart
Bogart Amelia Lynn
Bogart, Amelia Lynn
In middle digit filing, which file number would come after 16-20-55?
16-21-55
17-20-55
16-20-56
17-21-56
In middle digit filing, what is the tertiary number in 55-13-28?
28
13
55
How would you index and code the name Martin Victor O'Henry?
O'Henry, Martin Victor
Henry, Martin Victor
Henry, Martin Victor, O
Ohenry, Martin Victor
In terminal digit filing, which file number would come after 26-01-39?
26-01-40
26-02-39
27-02-40
27-01-39
Convert the terminal digit file number 16-84-03 to the middle digit system.
84-03-16
03-84-16
84-16-03
16-03-84
In terminal digit filing, what is the tertiary number in 55-08-12?
55
08
12
How would you index and code the name Peggy-Sue Jones?
Jones, Peggysue
Jones, Peggy (Sue)
Jones, Peggy Sue
Jones, Peggy-Sue
In numerical filing, what does the primary number represent?
The folder number
The medical facility
The drawer or shelf number
The subsection
How would you index and code the business Westerville's Apothecary?
Apothecary, Westerville's
Westerville's Apothecary
Apothecary, Westervilles
Westervilles Apothecary
In the numerical filing system, what is the alphabetical index of patient names and identification numbers?
Patient Registry
Master Patient Index
Numerical Patient Index
Cross-Reference
Which of the following may be deleted from a medical record?
A patient's progress notes over five years old
Studies showing abnormal results over ten years old
Insurance forms over seven years old
All of the above
Which of the following may be helpful for locating a missing file in the alphabetical system?
Check if the record was filed under the patient's first name.
Check for alternative spellings.
Check in folders with similar labels.
Check with other office workers.
All of the above
Which form should be included in a new medical record?
Patient Registration form
HIPAA Notice of Privacy Practices form
HIPAA Release of Information form
All of the above
After a patient completes treatment with a specialist physician, how long must the physician keep the medical records for that patient?
At least 5 years
At least 10 years
At least 15 years
As long as required by the statute of limitations
What is the process of sorting through old or inactive medical records?
Consolidating
Storing
Transferring
Purging
When is it acceptable to leave medical records out overnight?
When the records have been pulled for the next day's patients
When assistants do not have time to file the records
It is always acceptable to leave medical records out overnight.
It is never acceptable to leave medical records out overnight.
What is a good alternative to storing inactive medical records in a storage facility?
Transferring records to microforms
Destroying all inactive records
Filing inactive records with the active records
Which of the following should occur before an item is filed into the medical record?
It should be checked for completeness.
It should be checked for readability.
It should be checked for appropriate signatures.
All of the above
When a patient dies, how long must the medical records be kept by the medical facility?
At least 5 years
At least 10 years
At least 15 years
As long as required by the statute of limitations
Who has authority to decide when items may be deleted from a medical record?
Medical office assistants
Office supervisors
Physicians
Patients
What is the status of a medical record if the patient has passed away?
Active
Closed
Inactive
