Download 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 detailoriented 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.
37. (p. 153) The need to conserve space in many offices has made _____ files popular.
A. Centralized
B. Dead
C. Decentralized
D. Open-shelf files
The need to conserve space in many offices has made open-shelf files popular.
38. (p. 153) 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
Open-shelf files save time and labor.
39. (p. 153) 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
Centralized files and vertical files are arranged from front to back.
40. (p. 153) 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
Lateral files are arranged from left to right, instead of from front to back.
41. (p. 154) File folders may be open on how many sides?
A. One
B. Two
C. Three
D. Any of the above
File folders may be open on one, two, or three sides.
42. (p. 156) How many steps are included in filing?
A. Five
B. Four
C. Two
D. One
Five steps are included in filing.
43. (p. 156) _____ 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
Indexing is the mental process of selecting the name, title, or classification under which an
item will be filed.
44. (p. 156) _____ 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
Coding is the placing of a number, a letter, or an underscore beneath a word to indicate where
the document should be filed.
45. (p. 157) What type of file should be consulted daily?
A. Centralized
B. Tickler
C. Decentralized
D. Cross-reference
A tickler file should be consulted daily.
46. (p. 158) How many rules are there for alphabetic filing?
A. Four
B. Six
C. Eight
D. Ten
There are ten rules for alphabetic filing.
47. (p. 158) 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
It is estimated that 80 percent of healthcare facilities and 50 percent of physician practices that
have already implemented EHRs.
48. (p. 164) More than one person can/cannot use the stored data at the same time.
A. can
B. cannot
More than one person can use the stored data at the same time.
49. (p. 166) 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
Policies and procedures for updating medical personnel and evidence of the training should be
placed in the compliance manual.
50. (p. 167) 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
Until electronic health records are fully implemented into the healthcare system, scanners will
be needed.
51. (p. 167) Completely removing electronic data could give the appearance of _____ and is not
permissible in many programs.
A. Cheating
B. Liability
C. Fraud
D. Falsehood
Completely removing electronic data could give the appearance of fraud and is not
permissible in many programs.
52. (p. 168) _____ in medical documentation can lead to a vast array of consequences.
A. Information
B. Mistakes
C. Errors
D. Mistakes and errors
Mistakes and errors in medical documentation can lead to a vast array of consequences.
53. (p. 168) Transcriptionists use _____ to input medical data.
A. Keyboards
B. Templates
C. Pencils
D. Pens
Transcriptionists use templates to input medical data.
54. (p. 167) Which of the following abbreviations means "before meals"?
A. a.c.
B. b.c.
C. p.c.
D. b.m.
The abbreviation a.c. means "before meals".
55. (p. 167) Which of the following abbreviations means "twice per day"?
A. qid
B. tid
C. bid
D. qd
The abbreviation bid means "twice per day".
56. (p. 167) Which of the following abbreviations means "after meals"?
A. a.c.
B. b.c.
C. p.c.
D. qd
The abbreviation p.c. means "after meals".
57. (p. 128) 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.
Lyndia should regularly focus on distant objects to help ease eye strain while working.
58. (p. 139) 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.
To correct the error, Shannon should place a straight line through the entry, making sure it is
still legible; mark it "error", date her correction; and initial the correction.
59. (p. 145) 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
Dr. Crist used the CHEDDAR format.
60. (p. 166) 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
The acceptable chart notation for as needed is "p.r.n."
Fill in the Blank Questions
61. (p. 101) All chart notes must be signed and __________.
Dated
All chart notes must be signed and dated.
62. (p. 101) A(n) __________ may be used to send or receive information about the patient
immediately.
Fax machine
A fax machine may be used to send or receive information about the patient immediately.
63. (p. 94) After taking a message regarding a patient's care, the assistant should obtain the
__________.
Patient's chart.
After taking a message regarding a patient's care, the assistant should obtain the patient's
chart.
64. (p. 169) A technology being used in medical and other offices for data input is __________.
Voice Recognition Technology
A technology being used in medical and other offices for data input is voice recognition
technology.
65. (p. 166) After a patient encounter, the new electronic medical data should be reviewed and
__________ for errors.
Proofread
After a patient encounter, the new electronic medical data should be reviewed and proofread
for error.
66. (p. 164) Laws have been passed and large sums of money have, and are being invested in the
implementation of __________.
Healthcare reform
Laws have been passed and large sums of money have, and are being invested in the
implementation of healthcare reform.
67. (p. 162) Using the ______ system, it is easy to locate misfiled charts.
Color coding
Using the color coding system is easy to locate misfiled charts.
68. (p. 161) A book of consecutive numbers indicating the next available number to be assigned,
are assigned from an __________.
Accession book
A book of consecutive numbers indicating the next available number to be assigned, are
assigned from an accession book.