Medical Records Flashcards
Permission granted by an individual voluntarily and in his right mind is known as…
consent.
A medical office assistants’s family asks to see the medical information of her brother-in-law who has just been brought into the emergency room. If they accesses the information it is…
a violation of the Privacy Rule.
What is a role of a medical transcriptionist in the health care setting?
transforming medical information into a permanent document.
What is a characteristic of an EMR system used by a a medical office?
It is the principal medical record used in healthcare facilities.
In which medical record categories should the medical office assistant file a patient’s electrocardiogram result?
Diagnostic procedure documents.
A patient with Medicaid presents to the provider’s office requesting copies of medical records. The patient presents a valid ID and signs a consent form and the medical office assistant charges the patient $10.00 for the copies. What is true regarding this charge?
A provider can charge for the medical records because the records belong to the provider.
What medical report includes patient demographic information, dates of hospitalization, reason for, brief history, significant findings from exams and tests, course of treatment, final condition, and final diagnosis?
Discharge Summary Report
The medical assistant is contacting a patient to request they make a follow-up appointment. What form should the medical assistant verify prior to leaving this message on the patient’s voicemail?
HIPAA Confidentiality and Privacy
A patient presents to the outpatient department for a chest x-ray and sputum culture. The patient was referred from his primary care physician for a long-term cough. The resident physician provides the initial interpretation of the x-ray film and states “pneumonia” and signs the report. Seven days later the sputum culture indicates a streptococcal infection. Which of the following actions should the medical office assistant take?
Create an addendum because the new information must be connected to the original note.
Which federal regulation requires medical professionals to protect the privacy and confidentiality of patients’ health information?
HIPAA
A patient calls the office asking for ECG test results. The individual answering the phone should
let the patient know that the results cannot be discussed over the phone.
In 1996, Congress passed which of the following statutory laws to ensure that patient information and records will be kept confidential?
HIPAA (Health Insurance Portability and Accountability Act)
A phlebotomist’s failure to keep any or all privileged medical information private is called…
breach of confidentiality.
A patient’s blood work came back with a diagnosis of an infection. Which finding would also be seen on the patient results?
leukocytes
The patient who refuses to pay their medical bill at the established rate after receiving health care services is in breach of which of the following?
contract
