ALH 106 FINAL TEST/STUDY GUIDE chpt 9
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| A medical record ordered by the court to be available during a malpractice case is | subpeona
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| Medical record management requires | accuracy confidentiality proper documentation proper storage proper filing
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| Patient information in the medical record should include | personal and clinical information
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| The medical record must include information about patient care such as | diagnosis prescription information test results physical examination
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| A private or public healthcare entity that facilitates the processing of nonstandard electronic transactions into HIPAA transactions is a | insurance company clearinghouse covered intity WLAN WI-FI
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| A healthcare organization covered under HIPAA regulations is a | covered entity
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| A number assigned to an employer for purposes of identification is the | EIN
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| The individual or group that provides or pays for the patient’s medical care is the | Healthcare plan
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| A national source of reports of actions taken against healthcare providers, practitioners, and vendors who are in noncompliance or performing fraudulent activities is the | healthcare integrity and protection data bank
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| Conditions such as cancer, epilepsy, and congenital disorders of the newborn are often reported to government agencies in order to | maintain accurate public health statistics
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| An incomplete medical record may | may be difficult for a healthcare provider to defend allegations in court
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| For the court’s purpose, if documentation does not appear in the medical record, | it did not occur
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| Medical records should not be released to the patient without | the physicians knowledge and permission
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| The Privacy Act of 1974 provides private citizens some control over what | information the government collects about them and limits the use of information for unneccesary purposes
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| Under the Privacy Act of 1974 individuals were given the right to | find out what information was collected about them by the government see and have a copy of the information correct and ammend information exercise control over disclosure of their informartion
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| The privacy act only applies to federal agencies and government contractors | True of False
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| How long should medical records be stored for an adult | Reords should be stored for 10 years from the date of the last entry
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| How long should medical records be stored for a minor | the medical record for the minor should be kept until the age of maturity plus the period of the statute
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| list safeguards to help prevent the loss of a medical record | when medical charts are removed chart location should be recorded in a journal Insert a file indicator in place of the chart designate one person to be responsible for filing place all charts in a back up system like microche
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| Improper disclosure of a patients medical records can have | civil and criminal penalties
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| when a medical record is subpoenaed these guidelines should be followed except | physician notification patient notification copy the entire chart verify the trial date verify all of the information in the subpoena
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| What purpose does a medical record serve | it serves as a document that gives a medical picture and record of the patient from life to death
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| give an example of personal information in a medical record | name dob ss# rx refill # # of children
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| Give examples of clinical information found in a medical record | diagnosis CPT/ICD ss# rx refill #
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| What are the acronyms for JCAHO |
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| JCAHO and Medicare follow the same standard requirements for charting in the patient medical record; what is the requirement | timeliness
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| what is the correct way to make a correction in a paper chart |
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| what is the correct way to make a correction in an EMR |
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| Falsification of a medical record is grounds for criminal indictment | True of False
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| Federal reimbursement guidelines mandate that all med records should be completed within ___________ days following a patients discharge from the hospital |
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| An original version of the patients medical record should be sent when it is subpoenaed | True or False
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