Medical Records Flashcards

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Questions and Answers

Which of the following is not a method of organizing a medical record?

Problem oriented
Chronologically
Source oriented
Progressively (correct)

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?

The time when symptoms were first noticed
How many family members are healthy (correct)
Remedies the patient has tried to relieve symptoms (correct)
The duration of pain (correct)

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.

Indirect filing (A), Shingling (B), Direct filing (D) Signup and view all the answers

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?

Freeman, Jill M.D (B), Dr. Jill Freeman (C) Signup and view all the answers

How would you properly index the name "Amanda M. Stiles-Duncan" for filing?

Duncan, Amanda M. Stiles (B), Duncanstiles, Amanda M. (C), Stilesduncan, Amanda M. (D) Signup and view all the answers

Who is the legal owner of the information stored in a patient's record?

The physician or agency where services were provided (A), Both the patient and the physician (B), The patient (C), The patient's insurance company (D) Signup and view all the answers

Continuity of care means:

Medical attention that continues smoothly from one provider to another. (A), An aggregate of activities designed to ensure adequate quality. (C), Granted or endowed with a particular authority. (D) Signup and view all the answers

Which of the following are common types of filing equipment found in a medical office?

Rotary circular files (A), Lateral files (B), All of the above (D) Signup and view all the answers

Which of the following is not an advantage of color-coded filing systems?

Patient charts can be found quickly. (A), It is easy to tell when a file has been misplaced. (B), All of the above are advantages. (D) Signup and view all the answers

Which statement is not true regarding the reasons for keeping accurate medical records?

The patient's family may want to examine the records and correct errors. (A), Accurate records are vital for financial reimbursements. (B), The medical record provides critical information for other caregivers. (C) Signup and view all the answers

Which of the following is not objective information?

Progress notes (B), Family history (D) Signup and view all the answers

What is the most important reason for telling the physician when a charting error is discovered later?

To keep the patient from discovering the error (A), To protect the patient's health and well-being (B), To make sure the medical assistant is not accused of making the error (C), To protect the medical assistant's job (D) Signup and view all the answers

Which statement is not accurate about correcting charting errors?

In the margin, initial and date the error correction. (A), Draw two clear lines through the error. (B), Do not hide charting errors. (C), Insert the correction above or immediately after the error. (D) Signup and view all the answers

The medical record should be released only with a:

Written release from the patient. (B), Verbal order from the physician. (C) Signup and view all the answers

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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Description

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.