Chapter Concepts

Read each statement or question, and choose the answer that best completes the statement or question. Record the answer in the blank provided.

______1. Health information management personnel are responsible for all of the following except:

(a) Releasing medical records.

(b) Dictating medical reports.

(c) Compiling health carerelated statistics.

(d) Reviewing medical records for completeness.

______2. A medical record can be used for all of the following except:

(a) Publication in a medical journal.

(b) Planning for future health care services.

(c) Documentation in a legal case.

(d) Documentation for an insurance claim.

______3. All of the following are found in a medical record except:

(a) Results of laboratory tests.

(b) Patients medical history.

(c) Copy of the patients monthly bill.

(d) A letter from the physician to the patient.

______4. Which of the following is not a use of the medical record?

(a) Documentation of care given to a patient

(b) Review of patient care for quality assurance standards

(c) Medical education and research

(d) All are uses of a medical record.

(e) Only a and b are uses of a medical record.

______5. In which of the following circumstances should medical information be released?

(a) Attorney involved in litigation regarding a patient requests the patients medical record.

(b) An employer requests an employees medical record.

(c) Patients spouse requests results of a patients laboratory testing.

(d) Patient completes release of information form requesting information to be sent to another medical facility.

______6. What is the purpose of quantitative analysis?

(a) To determine whether the medical record is complete

(b) To identify health care procedures that need to be improved

(c) To tally errors made by physicians and nurses when documenting patient care

(d) To penalize office staff who need to improve

______7. Which of the following does not belong?

(a) Diagnosis

(b) Assessment

(c) Impression

(d) Examination

______8. What type of report would be used to document a patients office visit?

(a) SOAP note

(b) Assessment

(c) Summary

(d) Consultation

______9. Color coding of medical records will

(a) Eliminate the need to perform quantitative analysis on medical records.

(b) Increase the time required to file records.

(c) Reduce the number of medical records required.

(d) Make it easier to locate records.

______10. The proper way to correct an entry in a paper medical record is to

(a) Use correction fluid to ensure that the previous information is obliterated.

(b) Draw a single line through the incorrect entry.

(c) Erase the previous entry.

(d) Have the physician initial every correction made in a chart.

______11. All of the following are safeguards for electronic health records except:

(a) Track electronic files that an employee has accessed.

(b) Require use of a password to access the system.

(c) Limit computer accessibility to only those areas the employee needs to do his or her job.

(d) All of the above are safeguards.

(e) Only b and c are safeguards.

______12. All of the following are true regarding numerical filing except:

(a) Numbers are used only once.

(b) Terminal digit filing involves breaking a chart number into different parts when determining the location for filing.

(c) There is a greater chance of misfiling with a numerical system than with an alphabetical system.

(d) A number can be more confidential than a name.

______13. Which of the following is false regarding disaster preparations for medical records?

(a) Water-based sprinkler systems are recommended to protect records from fire.

(b) Medical office personnel must take precautions to protect records from fire, flood, and other natural or man-made disasters.

(c) Basement storage is NOT recommended for medical records.

(d) Destroyed records spell disaster for physicians and health care facilities.

______14. Which of the following must be signed when a patient wants his records transferred from one health care facility to another?

(a) Notice of Privacy Practices

(b) Release of Information

(c) Confidentiality Agreement

(d) All of the above

(e) None of the above

______15. Which of the following can protect the confidentiality of patients electronic health information?

(a) Allow employees to share passwords to make information more accessible.

(b) Allow all employees to access all areas of the system.

(c) Track employee use of the system.

(d) Discourage the use of screensavers and time limits if the system is inactive.