Questions and Answers
Which of the following is not a method of organizing a medical record?
Information that is gained by questioning the patient or that is taken from a form is called ____________ information.
subjective
Which of the following is not needed when describing a patient's chief complaint?
A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files is called a(n) __________ system.
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How would you properly index the name "Jill Freeman, M.D." for filing if you had another patient with the same name but without the title?
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How would you properly index the name "Amanda M. Stiles-Duncan" for filing?
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Who is the legal owner of the information stored in a patient's record?
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Continuity of care means:
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Which of the following are common types of filing equipment found in a medical office?
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Which of the following is not an advantage of color-coded filing systems?
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Which statement is not true regarding the reasons for keeping accurate medical records?
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Which of the following is not objective information?
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What is the most important reason for telling the physician when a charting error is discovered later?
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Which statement is not accurate about correcting charting errors?
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The medical record should be released only with a:
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Study Notes
Medical Record Organization
- Source Oriented and Problem Oriented are valid methods for organizing medical records; Progressively is not applicable.
- In medical records, subjective information is derived from patient questioning or form responses, whereas objective information is based on observable data.
Patient Chief Complaint
- Relevant details for a patient's chief complaint include remedies tried, duration of pain, and when symptoms started, but family health status is not necessary.
Filing Systems
- An indirect filing system requires consulting an intermediary source, such as a file card, to locate files.
- Proper indexing of names involves removing titles: "Jill Freeman, M.D." is indexed as Freeman, Jill M.D.
Legal Ownership of Records
- The entity legally owning patient record information is the physician or agency providing services, not the patient or insurance company.
Continuity of Care
- Continuity of care ensures seamless medical attention between providers for maximum patient benefit.
Filing Equipment and Color-Coding
- Common filing equipment in medical offices includes rotary circular files, lateral files, and automated files.
- Color-coded filing systems facilitate quick location and re-filing of patient charts, not presenting disadvantages.
Importance of Accurate Records
- Accurate medical records support efficient caregiving and aid in treatment tracking; however, family access for error correction is not a primary reason.
Objective vs. Subjective Information
- Objective information includes progress notes, diagnosis, and physical examinations, while family history falls under subjective data.
Charting Errors
- Timely reporting discovered charting errors is essential to protect patient health. Corrections should be noted properly with initialing and dating, avoiding unnecessary obscurity or misrepresentation of errors.
Release of Medical Records
- Medical records should only be released with a written release from the patient, not verbal orders.
Retention of Records for Minors
- Medical facilities are advised to maintain records on minors for a stipulated period, typically until they reach adulthood, which varies by jurisdiction.
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Test your knowledge on organizing medical records and understanding patient information with these flashcards. Each card presents a question related to medical documentation practices, enhancing your learning experience.
