Chapter 004 Managing Health Information

Chapter 004 Managing Health Information

Multiple Choice Questions

1.Another name for a central computer is:
A.A network
B.File server
C.Hard drive
D.Program

2.On-line medical _____ are used to educate physician's concerning conditions and treatment regimes.
A.Games
B.Companions
C.Databases
D.Courses

3.Most medical billing offices use a medical billing program such as:
A.Medicare
B.Medisoft
C.Medical Manager
D.Medidata

4.Accurate financial records are required for _____ and are critical for the practice's success.
A.Purchasing
B.Billing
C.Tax Reporting
D.Balancing

5.One of the most important tasks of an administrative medical assistant is the creation of:
A.Health insurance claims
B.Patient data
C.Practice documents
D.Patient accounts

6.The abbreviation EFT stands for:
A.Electronic funds trade
B.Electronic forms trade
C.Electronic forms transfer
D.Electronic funds transfer

7._____ computers are the most powerful computers available.
A.Mini
B.Super
C.Mainframe
D.Personal

8._____ computers are used in large businesses, hospitals, large clinics, and government organizations.
A.Mainframe
B.Mini
C.Super
D.Personal

9._____ computers have less power than mainframes.
A.Hospital
B.Super
C.Personal
D.Mini

10.To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between ______away.
A.1 and 1.5 feet
B.2 and 2.5 feet
C.3 and 3.5 feet
D.4 and 4.5 feet

11.A(n) _____ is a standard version of a document that is used over and over again.
A.Template
B.Form
C.Stencil
D.Sample

12._____ are assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail.
A.Locks
B.Log-ons
C.Permissions
D.Passwords

13.A patient's medical record constitutes the _____ record of the medical practice.
A.Established
B.Official
C.Legal
D.Valid

14.Making corrections to a chart with an eraser or scribbling out entries could present the appearance of ______.
A.A mistake
B.An error
C.Fraud
D.Cheating

15.If you make an error while recording an entry in the medical record, do all of the following except:
A.Write the word "error" next to the error
B.Write your initials next to error
C.Use correction tape to keep the entry neat.
D.Write the date next to the error.

16.Offices using electronic medical record entry methods should affix this to all chart entries:
A.A label
B.A validation code
C.An electronic date stamp
D.Electronic signature

17.A chronological record of ongoing patient care and progress is also known as:
A.A chart note
B.A chart plan
C.Patient note
D.Patient plan

18.What method is the most common system for outlining and structuring chart notes for a medical record?
A.CHEDDAR
B.SOAP
C.POMR
D.SOMR

19.This charting format breaks down the components of a patient encounter into seven detail-oriented sections:
A.CHEDDAR
B.SOAP
C.POMR
D.SOMR

20.The _____ findings in a SOAP record are the physician's examination of the patient.
A.Subjective
B.Objective

21.The _____ findings are the patient's description of the problem or the complaint.
A.Subjective
B.Objective

22.Based on the database and the initial problems of the patient, the physician:
A.Makes a diagnosis
B.Makes a prognosis
C.Begins a course of treatment
D.Defines an outcome

23.All medical records should be kept until:
A.The physician retires
B.The practice closes
C.The patient dies
D.The possibility of a malpractice suit has passed.

24.When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be:
A.Active
B.Closed
C.Inactive
D.Retired

25.What is the best measurement of the quality of care given to a patient?
A.The medical record
B.Patient compliance
C.The physician's reputation
D.Patient cure rate

26.Patients ____ the right to inspect their medical documentation.
A.Have
B.Do not have

27.This type of file pertains to current patients:
A.Inactive
B.Active
C.Closed
D.Closed storage

28.This type of file relates to patients who have not seen the physician for six months:
A.Active
B.Inactive
C.Closed
D.Closed storage

29.Federal law _____ regulate retention time frames for patient's medical records.
A.Does not
B.Does

30.All electronically stored records must be kept according to the _____ retention schedule as that for paper records.
A.Old
B.New
C.Same
D.Different

31.Records that have been closed and those that must be kept permanently are said to be in _____ storage, a storage area separate from the area where active files are kept.
A.Secure
B.Active
C.Safe
D.Dead

32.Dead storage ______be easily accessible.
A.Should
B.Should not

33.In the medical office, how many main types of records are there?
A.One
B.Two
C.Three
D.Four

34.The central responsibility of the physician's practice is:
A.Patient service
B.Patient care
C.Preventative visits
D.Patient well being

35.Which type of files are kept in one place?
A.Decentralized
B.Centralized
C.Dead
D.Open-shelf files

36.Information of use to only one staff member, such as a physician's correspondence, is stored in a _____ file convenient to the user.
A.Decentralized
B.Centralized
C.Dead
D.Open-shelf files

37.The need to conserve space in many offices has made _____ files popular.
A.Centralized
B.Dead
C.Decentralized
D.Open-shelf files

38.Which type of files save time and labor, but sacrifice some security?
A.Open-shelf files
B.Decentralized files
C.Dead files
D.Centralized files

39.Which type of files are arranged from front to back?
A.Open-shelf files
B.Centralized files
C.Vertical files
D.Centralized files and vertical files

40.Which type of files are arranged from left to right, instead of from front to back?
A.Open-shelf files
B.Centralized files
C.Vertical files
D.Lateral files

41.File folders may be open on how many sides?
A.One
B.Two
C.Three
D.Any of the above

42.How many steps are included in filing?
A.Five
B.Four
C.Two
D.One

43._____ is the mental process of selecting the name, title, or classification under which an item will be filed.
A.Sorting
B.Storing
C.Coding
D.Indexing

44._____ is the placing of a number, a letter, or an underscore beneath a word to indicate where the document should be filed.
A.Coding
B.Indexing
C.Sorting
D.Storing

45.What type of file should be consulted daily?
A.Centralized
B.Tickler
C.Decentralized
D.Cross-reference

46.How many rules are there for alphabetic filing?
A.Four
B.Six
C.Eight
D.Ten

47.It is estimated that _____ percent of healthcare facilities and _____ percent of physician practices that have already implemented EHRs.
A.60, 40
B.70, 30
C.80, 50
D.90, 60

48.More than one person can/cannot use the stored data at the same time.
A.can
B.cannot

49.Policies and procedures for updating medical personnel and evidence of the training should be placed in the _____.
A.Compliance manual
B.Personnel manual
C.Procedure manual
D.Rule manual

50.Until electronic health records are fully implemented into the healthcare system, _____ will be needed.
A.Fax machines
B.Temporary personnel
C.File clerks
D.Scanners

51.Completely removing electronic data could give the appearance of _____ and is not permissible in many programs.
A.Cheating
B.Liability
C.Fraud
D.Falsehood

52._____ in medical documentation can lead to a vast array of consequences.
A.Information
B.Mistakes
C.Errors
D.Mistakes and errors

53.Transcriptionists use _____ to input medical data.
A.Keyboards
B.Templates
C.Pencils
D.Pens

54.Which of the following abbreviations means "before meals"?
A.a.c.
B.b.c.
C.p.c.
D.b.m.

55.Which of the following abbreviations means "twice per day"?
A.qid
B.tid
C.bid
D.qd

56.Which of the following abbreviations means "after meals"?
A.a.c.
B.b.c.
C.p.c.
D.qd

57.Lyndia works exclusively inputting data into medical records. She seldom takes a break from inputting and works 4 days per week, 10 hours each day. While driving, she notices a change in her distance vision. Choose which of the following she should do to help ease eye strain while working.
A.Place her hands and wrists in horizontal alignment.
B.Regularly focus on distant objects.
C.Place source documents flat beside her computer.
D.Frequently rotate her neck and shoulders.

58.Shannon works for a medical practice that uses the first three letters of the patient's last name and the date of birth as the patient numbers. When Shannon was filing medical insurance claims, she noticed that a chart note had been made in the wrong chart. The physician sees twin females, and the chart for the wrong twin had been noted. To correct the error, Shannon should:
A.Eliminate the chart note with correction fluid.
B.Use a wide, permanent black marker to cross out the chart note.
C.Place a straight line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction.
D.Place a wavy line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction.

59.When Dr. Crist opened the EHR for her next patient, she was able to quickly view a listing of all patients' current and previously treated medical conditions. Choose which documentation format Dr. Crist uses.
A.SOAP
B.CHEDDAR
C.DATABASE
D.POMR

60.Choose which of the following is an acceptable chart notation for "as needed":
A.q.4h
B.p.r.n.
C.a.n.
D.as ndd

Fill in the Blank Questions

61.All chart notes must be signed and ______.
______

62.A(n) ______may be used to send or receive information about the patient immediately.
______

63.After taking a message regarding a patient's care, the assistant should obtain the ______.
______

64.A technology being used in medical and other offices for data input is ______.
______

65.After a patient encounter, the new electronic medical data should be reviewed and ______for errors.
______

66.Laws have been passed and large sums of money have, and are being invested in the implementation of ______.
______

67.Using the ______system, it is easy to locate misfiled charts.
______

68.A book of consecutive numbers indicating the next available number to be assigned, are assigned from an ______.
______

Chapter 004 Managing Health Information

Multiple Choice Questions

Anwsers

1.(p.131)Another name for a central computer is:
A.A network
B.File server
C.Hard drive
D.Program

Another name for a central computer is a file server.

2.(p.131)On-line medical _____ are used to educate physician's concerning conditions and treatment regimes.
A.Games
B.Companions
C.Databases
D.Courses

On-line medical databases are used to educate physician's concerning conditions and treatment regimes.

3.(p.132)Most medical billing offices use a medical billing program such as:
A.Medicare
B.Medisoft
C.Medical Manager
D.Medidata

Most medical billing offices use a medical billing program such as Medisoft.

4.(p.132)Accurate financial records are required for _____ and are critical for the practice's success.
A.Purchasing
B.Billing
C.Tax Reporting
D.Balancing

Accurate financial records are required for tax reporting and are critical for the practice's success.

5.(p.132)One of the most important tasks of an administrative medical assistant is the creation of:
A.Health insurance claims
B.Patient data
C.Practice documents
D.Patient accounts

One of the most important tasks of an administrative medical assistant is the creation of health insurance claims.

6.(p.132)The abbreviation EFT stands for:
A.Electronic funds trade
B.Electronic forms trade
C.Electronic forms transfer
D.Electronic funds transfer

The abbreviation EFT stands for electronic funds transfer.

7.(p.133)_____ computers are the most powerful computers available.
A.Mini
B.Super
C.Mainframe
D.Personal

Supercomputers are the most powerful computers available.

8.(p.133)_____ computers are used in large businesses, hospitals, large clinics, and government organizations.
A.Mainframe
B.Mini
C.Super
D.Personal

Mainframe computers are used in large businesses, hospitals, large clinics, and government organizations.

9.(p.134)_____ computers have less power than mainframes.
A.Hospital
B.Super
C.Personal
D.Mini

Mini computers have less power than mainframes.

10.(p.135)To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between ______away.
A.1 and 1.5 feet
B.2 and 2.5 feet
C.3 and 3.5 feet
D.4 and 4.5 feet

To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between 2 and 2.5 feet away.

11.(p.136)A(n) _____ is a standard version of a document that is used over and over again.
A.Template
B.Form
C.Stencil
D.Sample

A template is a standard version of a document that is used over and over again.

12.(p.138)_____ are assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail.
A.Locks
B.Log-ons
C.Permissions
D.Passwords

Passwords are assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail.

13.(p.139)A patient's medical record constitutes the _____ record of the medical practice.
A.Established
B.Official
C.Legal
D.Valid

A patient's medical record constitutes the legal record of the medical practice.

14.(p.141)Making corrections to a chart with an eraser or scribbling out entries could present the appearance of ______.
A.A mistake
B.An error
C.Fraud
D.Cheating

Making corrections to a chart with an eraser or scribbling out entries could present the appearance of fraud.

15.(p.141)If you make an error while recording an entry in the medical record, do all of the following except:
A.Write the word "error" next to the error
B.Write your initials next to error
C.Use correction tape to keep the entry neat.
D.Write the date next to the error.

If you make an error while recording an entry in the medical record, do not use correction tape to keep the entry neat.

16.(p.141)Offices using electronic medical record entry methods should affix this to all chart entries:
A.A label
B.A validation code
C.An electronic date stamp
D.Electronic signature

Offices using electronic medical record entry methods should affix an electronic signature to all chart entries.

17.(p.149)A chronological record of ongoing patient care and progress is also known as:
A.A chart note
B.A chart plan
C.Patient note
D.Patient plan

A patient note is a chronological record of ongoing patient care and progress.

18.(p.142)What method is the most common system for outlining and structuring chart notes for a medical record?
A.CHEDDAR
B.SOAP
C.POMR
D.SOMR

The SOAP method is the most common system for outlining and structuring chart notes for a medical record.

19.(p.142)This charting format breaks down the components of a patient encounter into seven detail-oriented sections:
A.CHEDDAR
B.SOAP
C.POMR
D.SOMR

The SOAP charting format breaks down the components of a patient encounter into seven detail oriented sections.

20.(p.143)The _____ findings in a SOAP record are the physician's examination of the patient.
A.Subjective
B.Objective

The objective findings in a SOAP record are the physician's examination of the patient.

21.(p.142)The _____ findings are the patient's description of the problem or the complaint.
A.Subjective
B.Objective

The subjective findings are the patient's description of the problem or the complaint.

22.(p.147)Based on the database and the initial problems of the patient, the physician:
A.Makes a diagnosis
B.Makes a prognosis
C.Begins a course of treatment
D.Defines an outcome

Based on the database and the initial problems of the patient, the physician begins a course of treatment.

23.(p.147)All medical records should be kept until:
A.The physician retires
B.The practice closes
C.The patient dies
D.The possibility of a malpractice suit has passed.

All medical records should be kept until the possibility of a malpractice suit has passed.

24.(p.147)When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be:
A.Active
B.Closed
C.Inactive
D.Retired

When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be closed.

25.(p.149)What is the best measurement of the quality of care given to a patient?
A.The medical record
B.Patient compliance
C.The physician's reputation
D.Patient cure rate

The best measurement of the quality of care given to a patient is the medical record.

26.(p.149)Patients ____ the right to inspect their medical documentation.
A.Have
B.Do not have

Patients have the right to inspect their medical documentation.

27.(p.149)This type of file pertains to current patients:
A.Inactive
B.Active
C.Closed
D.Closed storage

An active file pertains to current patients.

28.(p.149)This type of file relates to patients who have not seen the physician for six months:
A.Active
B.Inactive
C.Closed
D.Closed storage

An inactive file relates to patients who have not seen the physician for six months.

29.(p.150)Federal law _____ regulate retention time frames for patient's medical records.
A.Does not
B.Does

Federal law does not regulate retention time frames for patient's medical records

30.(p.151)All electronically stored records must be kept according to the _____ retention schedule as that for paper records.
A.Old
B.New
C.Same
D.Different

All electronically stored records must be kept according to the same retention schedule as that for old papers.

31.(p.151)Records that have been closed and those that must be kept permanently are said to be in _____ storage, a storage area separate from the area where active files are kept.
A.Secure
B.Active
C.Safe
D.Dead

Records that have been closed and those that must be kept permanently are said to be in dead storage, or storage separate from the area where active files are kept.

32.(p.151)Dead storage ______be easily accessible.
A.Should
B.Should not

Dead storage should be easily accessible.

33.(p.152)In the medical office, how many main types of records are there?
A.One
B.Two
C.Three
D.Four

There are three main types of records in the medical office: patient medical records, correspondence related to healthcare, and practice management records.

34.(p.152)The central responsibility of the physician's practice is:
A.Patient service
B.Patient care
C.Preventative visits
D.Patient well being

The central responsibility of the physician's practice is patient care.

35.(p.152)Which type of files are kept in one place?
A.Decentralized
B.Centralized
C.Dead
D.Open-shelf files

Centralized files are kept in one place.

36.(p.152)Information of use to only one staff member, such as a physician's correspondence, is stored in a _____ file convenient to the user.
A.Decentralized
B.Centralized
C.Dead
D.Open-shelf files

Information of use to only one staff member, such as a physician's correspondence, is stored in a decentralized file convenient for the user.