MOP Chapter 14- Medical Records Management – Flashcards
Unlock all answers in this set
Unlock answersquestion
What is the most important ethical reason to maintain accurate medical records?
answer
Continuity of patient care
question
What filing tool could you use to track a patient's chart which has been removed from the storage area?
answer
Out guides
question
How should you correct an error in a medical record?
answer
In red ink, draw a red line through the error, with the word CORR or Correction with your name/initials and date
question
What type of coding systems are commonly used in ambulatory care centers?
answer
Alphabetic, numeric, and subject
question
What is the most important information to put on an out guide?
answer
Who has the file, Where the file is, When the file was taken out, When the expected return date is
question
The greatest bulk of information generated by medical facilities comes from what?
answer
Patient medical records
question
Why would you use cross-reference filing?
answer
To find a specific record that may be filed under more than one name/sunject
question
What do we call a filing method that serves as a reminder for future actions?
answer
Tickler File
question
What do we call the process of sorting through records and removing those that are not active?
answer
Purging
question
When using a tickler file, what should be listed on the reminder?
answer
Patient name, Tickler date, Required action, Any additional relevant information
question
What method of arranging charts uses a page that lists vital identification data, immunizations, allergies, medications and problems?
answer
Problem-Oriented medical records (POMR)
question
What do we call records that need to be readily accessible for retrieval of information?
answer
Active files
question
What is the primary use of out guides?
answer
To help track charts
question
Where would you file information for non-patient services?
answer
Miscellaneous
question
What's the legal standard if there is no written record of a temperature, a visit, a history, physical, or a lab report?
answer
If it isn't charted, it didn't happen
question
What format should be used for a patient's name on a medical chart?
answer
Indexing- Last name, First name, Middle name
question
What would you need to consider when choosing a patient filing system?
answer
How the charts will primarily be used, The number of documents filed, If the information needs to be tracked by others
question
What type of filing systems would be most appropriate when you have a large amount of patients?
answer
Numeric system
question
What type of filing cabinets is most appropriate for an office with a large record system?
answer
Movable File Units
question
What type of medical record format contains a problem list?
answer
SOAP/ER
question
Movable file units require how much space compared to vertical or lateral files?
answer
Much less
question
What do we call it when EMRs from multiple sources are combined into one database for a patient?
answer
EHRs (Electronic Health Records)
question
President George Bush's 2004 Health Information Technology Plan included the goal that most Americans would have electronic health records by what year?
answer
2014 changed 2015
question
Who is least likely to use EMRs?
answer
small offices with one provider
question
What are the HIPAA standards in regards to EMRs?
answer
-Computers, network hubs and servers must be secure from intrusion -Users who access medical information are to be identified and updated regularly -Firewalls and antivirus measures must block unauthorized access -Passwords are not to be easily guessed, must be securely stored, and should be changed no fewer than every 90 days -Passwords are to be hidden when entered and are not shared with anyone -The number of invalid entries to access information must be limited -Computer screens are to be out of view of unauthorized individuals -Screensavers are used for further protection when there is no computer activity
