MDAST 322 Chapter 10 Exam Questions And Answers Practice Questions with Solutions Newest | Already Graded A+

MDAST 322 Chapter 10 Exam Questions And Answers Practice Questions with Solutions Newest | Already Graded A+ The patient owns the medical record. • True • False - Answer- False The maker of the medical record is its owner; in the physician's office, the physician is the maker/owner of patient medical records. HIPAA recommends that physicians keep the records on patients for at least: • 1 year, • 2 years • 3 years. • HIPAA does not recommend a number of years. - Answer- HIPAA does not recommend a number of years. HIPAA does not offer a recommendation on record retention; it prompts facilities to follow their individual state laws. Reverse chronologic order is where the most recent item is on the top and older items are filed farther back. • True • False - Answer- True Reverse chronologic order is where the most recent item is on the top and older items are filed farther back. Which of the following are common types of filing equipment found in a medical office? • Rotary circular files • Lateral files • Automated files • All are correct - Answer- All are correct Rotary circular files, lateral files, and automated files are all types of filing equipment that might be found in a medical office. By legal definition, if it is not documented, then it did not happen. • True • False - Answer- True If an action is not documented in the health record, then it is considered not to have happened. Who ultimately decides whether a medical record can be released? • The physician • The office manager • The medical assistant • The patient - Answer- The patient The patient ultimately decides whether his or her medical record can be released. The "E" entry in the SOAPER charting method means: • entry. • evaluation. • education. • exclude. • evaluation or education - Answer- evaluation or education The "E" entry signifies either patient education or the physician's evaluation that occurred during the encounter with the patient. The source-oriented medical record (SOMR) categorizes the content by its source, such as provider, laboratory, radiology, hospital, and consultation.The problems and elaborates on the problem-oriented medical record (POMR) categorizes each of the patient's findings and treatment plans for all concerns • Both statements are true • Both statments are false • First statement is true second statement is talse. • First statement is false, second statement - Answer- Both statements are true The source-oriented medical record (SOMR) its source, such as provider, laboratory, radiology, hospital, and consultation. Within each source category the content is arranged in reverse chronologic order so that the most recent content is viewed categorizes the content by first. The problem-oriented medical record (POMR) categorizes each of the for all concerns. patient's problems and elaborates on the findings and treatment plans Detailed progress notes are kept for each individual problem. This method addresses each of the patient's concerns separately, whereas a source-oriented record may address all problems and concerns at one time, usually covering one to three patient concerms per office visit. The POMR helps ensure that individual problems are all addressed. that can be created, gathered, The type of electronic record of health-related information about an individual managed, and consulted only by authorized clinicians and staff in a single healthcare organization is aln): • PHR. • EHR. • EMR. • PHI - Answer- EMR. The EMR is compiled by the staff at a single organization involved in the patient's care. Which statement is not accurate about correcting charting errors? • Insert the correction above or immediately after the error. • Draw two clear lines through the error. • In the margin, initial and date the error correction. • Do not hide charting errors. - Answer- Draw two clear lines through the error. Only one line should be drawn through errors when corrections are made. The computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages. • True • False - Answer- False Both computer-based and paper-based records have advantages and disadvantages. The medical record should be released only with a: • verbal order from the physician. • written order from the physician. • written release from the patient. • verbal order from the office manager. - Answer- written release from the patient. Records should be released only with a written authorization from the patient. Which section of the law, commonly known as the Economic Stimulus Package, pertains to healthcare? • ARRA • HITECH Act • HIPAA • None are correct - Answer- HITECH Act