Question 1

Subjective information is that which the physician observes during the physical examination of the patient.

Accepted Answer

A) True 
 B)False  False

Question 2

The healthcare industry is one of constant __________, and the medical assistant is expected to stay abreast of current trends, laws, and requirements.

Accepted Answer

The answer of The healthcare industry is one of constant...

Question 3

For a record to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written. The best indication of this is the provider's signature or initials on the typed or EHR entry.

Accepted Answer

A)   Both statements are true.
B)   Both statements are false.
C)   The first statement is true; the second is false.
D)   The first statement is false; the second is true.E) B) and C)
F) A) and C)

Question 4

Information picked up bit by bit is said to be __________.

Accepted Answer

The answer of Information picked up bit by bit is...

Question 5

When documents are added to a patient's chart, the most recent information should be placed on top.

Accepted Answer

A) True 
 B)False

Question 6

What is the HIPAA privacy rule requirement for the retention of health records?

Accepted Answer

A)   HIPAA does not include requirements.
B)   Records must be kept for at least 10 years.
C)   For at least the period of the statute of limitations for medical malpractice claims
D)   Until the minor reaches the age of majority plus the statute of limitationsE) B) and C)
F) A) and B)

Question 7

The type of electronic record of health-related information about an individual that can be created, gathered, managed, and consulted only by authorized clinicians and staff in a single healthcare organization is a(n)

Accepted Answer

A)   PHR.
B)   EHR.
C)   EMR.
D)   PHI.E) A) and B)
F) All of the above

Question 8

A standard, nationwide rule must be followed in establishing a records retention schedule.

Accepted Answer

A) True 
 B)False  False

Question 9

The EHR system should be backed up __________.

Accepted Answer

The answer of The EHR system should be backed up...

Question 10

A process of electronic data entry of medical practitioner or provider instructions for the treatment of patients is called _______________.

Accepted Answer

computerized physici...

Question 11

Entities considered essential or necessary are called __________.

Accepted Answer

The answer of Entities considered essential or necessary are called...

Question 12

An aggregate of activities designed to ensure adequate quality is called quality control.

Accepted Answer

A) True 
 B)False  True

Question 13

Remember that all backup systems need __________ to run.

Accepted Answer

The answer of Remember that all backup systems need __________...

Question 14

Medical facilities should keep records on minors for how long?

Accepted Answer

A)   Indefinitely
B)   Until the minor is deceased
C)   For 10 years
D)   Until the minor reaches the age of majority, plus 3 yearsE) All of the above
F) C) and D)

Question 15

When a patient is transferred from one facility to another, __________ of care ensures that no lapses in treatment occur and that transitions are smooth.

Accepted Answer

The answer of When a patient is transferred from one...

Question 16

Continuity of care means

Accepted Answer

A)   an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries.
B)   a formal examination of an organization's or individual's accounts.
C)   medical attention that continues smoothly from one provider to another so that the patient receives the most benefit.
D)   granted or endowed with a particular authority.E) B) and D)
F) C) and D)

Question 17

How can the EHR function to best help improve a facility's appointment show rate?

Accepted Answer

A)   The system can matrix the schedule with input from a staff member.
B)   The system can be programmed to initiate reminder and confirmation calls to patients.
C)   The system will allow searches for patient appointments based on a few parameters.
D)   The system can generate a list of the confirmed appointments.E) A) and C)
F) None of the above

Question 18

Reverse chronologic order is where the most recent item is on the top and older items are filed farther back.

Accepted Answer

A) True 
 B)False

Question 19

The "R" entry in the SOAPER charting method means

Accepted Answer

A)   rationale.
B)   response.
C)   repeat.
D)   reinforce.E) C) and D)
F) None of the above

Question 20

A filing system in which an intermediary source of reference, such as a card file, must be consulted to locate specific files, is called a(n) __________ system.

Accepted Answer

The answer of A filing system in which an intermediary...

Exam 11: The Health Record

Subjective information is that which the physician observes during the physical examination of the patient.

Correct AnswerverifiedFalse

The healthcare industry is one of constant __________, and the medical assistant is expected to stay abreast of current trends, laws, and requirements.

Correct AnswerverifiedShow Answer

For a record to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written. The best indication of this is the provider's signature or initials on the typed or EHR entry.

Correct AnswerverifiedShow Answer

Information picked up bit by bit is said to be __________.

Correct AnswerverifiedShow Answer

When documents are added to a patient's chart, the most recent information should be placed on top.

Correct AnswerverifiedShow Answer

What is the HIPAA privacy rule requirement for the retention of health records?

Correct AnswerverifiedShow Answer

The type of electronic record of health-related information about an individual that can be created, gathered, managed, and consulted only by authorized clinicians and staff in a single healthcare organization is a(n)

Correct AnswerverifiedShow Answer

A standard, nationwide rule must be followed in establishing a records retention schedule.

Correct AnswerverifiedFalse

The EHR system should be backed up __________.

Correct AnswerverifiedShow Answer

A process of electronic data entry of medical practitioner or provider instructions for the treatment of patients is called _______________.

Correct Answerverifiedcomputerized physici...View AnswerShow Answer

Entities considered essential or necessary are called __________.

Correct AnswerverifiedShow Answer

An aggregate of activities designed to ensure adequate quality is called quality control.

Correct AnswerverifiedTrue

Remember that all backup systems need __________ to run.

Correct AnswerverifiedShow Answer

Medical facilities should keep records on minors for how long?

Correct AnswerverifiedShow Answer

When a patient is transferred from one facility to another, __________ of care ensures that no lapses in treatment occur and that transitions are smooth.

Correct AnswerverifiedShow Answer

Continuity of care means

Correct AnswerverifiedShow Answer

How can the EHR function to best help improve a facility's appointment show rate?

Correct AnswerverifiedShow Answer

Reverse chronologic order is where the most recent item is on the top and older items are filed farther back.

Correct AnswerverifiedShow Answer

The "R" entry in the SOAPER charting method means

Correct AnswerverifiedShow Answer

A filing system in which an intermediary source of reference, such as a card file, must be consulted to locate specific files, is called a(n) __________ system.

Correct AnswerverifiedShow Answer

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False

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False

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computerized physici...
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True

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