Chapters 1-3

Question 1

What is the purpose of date and time stamping in medical transcription?

Answer 1

A. To allow reimbursement
B. To help create an audit trail
C. To indicate the date treatment was provided
D. To identify the transcriptionist

B

Question 2

Which expression is included in the record to meet HIPAA security requirements?

Answer 2

A. AXIS II
B. T1NXMX
C. T: 12/31/11, 1500
D. Dictated but not read.

C

Question 3

What does HIPAA stand for?

Answer 3

Health Insurance Portability and Accountability Act

Question 4

What does PHI stand for under the HIPAA definition?

Answer 4

Protected Health Information

Question 5

According to HIPAA, PHI includes a information in what form?

Answer 5

On paper, electronically transmitted, and orally transmitted

Question 6

Which would be a violation of the HIPAA privacy rule?

Answer 6

A. Releasing information relating to patient’s care to a third-party insurance billing company.
B. Disclosing information about an individual’s health in a phone call.
C. Releasing information about a patient’s health status to public health authorities.
D. Using de-identifying health record for clinical study or statistical research.

A

Question 7

Which individual is considered an accountable party under HIPAA?

Answer 7

A. An employee of a covered entity.
B. An employee of a transcription service.
C. A business associate of a covered entity.
D. An employee of a federally funded healthcare facility

C

Question 8

According to the Joint Commission, an admitting history and physical examination must be completed no more than _____ hours of inpatient admission?

Answer 8

Within 24 hours

Question 9

What typical TAT is established by most facilities for dictation of a discharge summary?

Answer 9

30 days

Question 10

What is the “Basic Four” acute care document types

Answer 10

1. History and physical
2. Consultation reports
3. Operative reports
4. Discharge summaries

Question 11

ADT refers to ______data?

Answer 11

Admission/Discharge/Transfer

Question 12

According to HL7, what should be done to a dictated addendum?

Answer 12

Transcribed in a new document with its own document ID

Question 13

The process by which a provider verifies what has been captured in the record and affixes their signature to the report is called:

Answer 13

Authentication

Question 14

What is FULL BLOCK FORMATION?

Answer 14

All text begins flush with the left margin (date, address, reference line, salutation).

Question 15

What is MODIFIED BLOCK FORMAT?

Answer 15

Date, complimentary close, and signature line are placed just to the right of middle.

Question 16

In a document, What heading information are required to be listed vertically?

Answer 16

Chief complaint
Diagnosis
Preoperative diagnosis
Postoperative diagnosis
Names of operations.

Question 17

All phrases end with a period with the exception of?

Answer 17

Date or the name of a person (NO period)

Question 18

What is syntax?

Answer 18

Word arrangement. ESL dictators are particularly prone to errors in syntax.

Question 19

Jargon

Answer 19

The technical terminology or characteristic idiom of a special activity or group. Eg., premie, urines, orthopedist

Medical jargon tends to be imprecise and may be offensive and derogatory. Only use in quotes

Question 20

Brief forms

Answer 20

Shortened forms of common words that are acceptable to transcribe in abbreviated format.

Acceptable: exam, lab, prep, monos, basis, lymphs, eos
Unacceptable: appy, crit, epi, flex sig, lab Chloe

Question 21

Back Formations

Answer 21

New words formed by altering an existing word.

Use if they have become accepted through wide-spread use.

Acceptable: diagnosis - to diagnose; Bovie - bovied
Unacceptable: adhesion - adhese; liaison - to liase; orchiopex - pep

Question 22

What is a covered entity?

Answer 22

Those that generate individually identifiable patient health information and therefore have primary responsibility for maintaining the privacy and confidentiality of this information.

E.g.,
Most health plans
Healthcare clearing houses.
Healthcare providers that transmit any health information in electronic form in connection with certain administrative transactions related to payment for health care i.e., Hospitals, nursing homes, clinics, physicians offices,

Question 23

Permitted disclosures

Answer 23

Covered entities can disclose PHI for treatment, payment, or healthcare operations without any prior consent/authorization from patient.