MOP Chapter 14- Medical Records Management – Flashcards

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