CH 43 Medical Records Management – Flashcards
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Both paper medical records and electronic medical records
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Which of the following types of medical records may be reviewed to record statistical information?
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They provide for continuity of care, They provide an ongoing record of the pt's state of health, They are legal documents if there is a question about care given, They usually include information from more than one source (All the above)
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Which of the following are true about both paper medical records and electronic medical records?
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Baseline data and recent information is scanned into the electronic record, and the paper record is kept available for two to three years
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What usually happens to the paper medical record after a medical office transitions to an electronic health record system?
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Manila folders with one or more tabs on the side that opens
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What is used to hold medical records if they are filed in an ordinary file cabinet?
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Pressure-sensitive self-adhesive labels are usually used
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What is true about labels used on paper medical records?
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Vertical drawer file cabinets, Open-shelf filing units arranged horizontally, Shelf filing units with pull-down fronts, Lateral drawer file cabinets (All of the above)
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What is used to hold the medical records if the medical office uses a paper medical record?
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A means to lock the medical record storage cabinets or storage room
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What is always necessary if a paper medical system is used?
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When the width of the folder reaches 3/4th in
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When is it recommended that file folders used to hold paper medical records be broken down into two folders?
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A stiff piece of paper or plastic that is placed in a file when a medical record is removed.
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What is an outguide?
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Numeric
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Which of the following is an indirect method of filing?
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It reduces the risk of misfiling
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What is an advantage of using color-coded labels or folders?
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All office staff
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If the office is using a color-coded system, who needs to know the meaning of the colors in use?
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Using mounting sheets, with the oldest report at the back on the bottom.
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In a paper medical record system, how are laboratory reports often filed if they are smaller than 9x12 inches?
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Each part of a patient's name
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What is an indexing unit in alphabetic filing?
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Last name
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What is the first indexing unit in alphabetic filing?
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First name
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What is the second indexing unit in alphabetic filing?
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Street address
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If two pt's have exactly the same name, what information is used to put their medical records in order?
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Numeric
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Which filing system used for paper medical records protects pt id most successfully?
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Jones, Jane
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Which of the following would be filed first?
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H
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Using the alphabetic system of filing, what would "The Harris Office Supply Company" be filed under?
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Winston De La Mare
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Which of the following names would be filed first?
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Bower, Edgar Lawrence
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Which of the following names would be filed last?
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St. Charles, Josephine
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Which of the following names would be filed first?
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All the above
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If Mary Jane Mitchell marries John L. Walker, which of the following names might Mary Jane choose to use as her married name?
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A separate system must be maintained to link the pt's name with the numbering system
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Which of the following is NOT an advantage of using a numeric filing system?
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59
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If the terminal digit filing system is used, what is the first filing unit for the number 01-68-72-59?
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72-81-19-02
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If the terminal digit filing system is used, which of the following medical record numbers comes first in the files?
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7281
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If a chronological numeric filing system is used, which of the following medical records comes last in the files?
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Filing out a card to place in the outguide for every record that was re,oved
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Which of the following makes it easier to find a paper medical record that has been removed from the files?
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In a desk or file cabinet near where the MA usually sits
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Where should the MA's paper tickler files be stored?
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Bank accounts
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If the subject method of filing is used for folders, which of the following would be filed first?
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It must be initialed by the physician
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What must occur before a piece of correspondence can be filed in a pt's paper medical record?
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In reverse chronological order (most recent first)
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In what order are documents filed into a section of the source-oriented medical record?
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Office policy
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What determines the classification of "inactive" for a medical record?
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Until the patient reaches the age of majority plus the number of years for the statute of limitations in that particular state.
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How long should the medical records of minors be kept?
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When the record has been inactive at least seven years after the statue of limitations has expired
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When can a physician destroy a pt's file?
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External hard drive
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Which of the following is the least common method for backing up the electronic medical record?
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To create more apace for the records of new pt's
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Why are inactive records removed from the active file area in most offices?
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If possible, they should be stored off site in a secure location
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What is a guideline for the storage of backup copies of electronic medical records?
