Record Mangement

Question 1

Subject

Answer 1

Patient gives by questions

Question 2

Chief complaint is not

Answer 2

Going to include family history

Question 3

Direct filing

Answer 3

Alphabetic cross reference to locate certain files

Question 4

How is a doctor name written

Answer 4

Last name, first (title)

Question 5

No - in

Answer 5

Last name for example Douglas- smith would be douglassmith

Question 6

Physician needs

Answer 6

Accurate records to provide appropriate care

Question 7

A written release from a patient

Answer 7

Is required to release medical records

Question 8

Transcription software can be used

Answer 8

To dictate progress notes, emails and letters

Question 9

Tacular files

Answer 9

Most frequently used

Question 10

Follow-up method

Answer 10

To remind patient to follow up

Question 11

Closed files

Answer 11

Patients files who have died, moved or terminated the relationship with physician

Question 12

Purging

Answer 12

Moving active file to nonactive status

Question 13

Physical record

Answer 13

Belongs to physician/medical provider

Question 14

EHR

Answer 14

System can be created, manged, and consulted by clinical staff for more than one healthcare organization

Question 15

Electronic health record

Answer 15

Needs to be corrected with a new entry to original with correct info, and initialed

Question 16

While meeting patient and filing record

Answer 16

Keep making eye contact

Question 17

Record goes to court for evidence

Answer 17

For it to be admissible whoever wrote the entry, true and correct at time written will need a providers signature

Question 18

Handwritten records can’t have

Answer 18

White out or erasing

Question 19

Numeric

Answer 19

Indirect filing used by hospitals and bigger clinics

Question 20

What is a chief complaint

Answer 20

Patient symptoms in own words

Question 21

EHR system helps what?

Answer 21

Reduce medical errors

Question 22

Cpoe

Answer 22

Process of electronic data entry of provider instructions for patient treatment

Question 23

When is EHR backed up

Answer 23

Daily

Question 24

PHI

Answer 24

Protective health info

Question 25

Problem Oriented

Answer 25

Type of medical organization with four components data, problem list, treatment, progress notes

Question 26

Source oriented

Answer 26

Type of medical organization that includes observation and data category in sections

Question 27

Meaningful use of requirement

Answer 27

EHR for e-prescribing, cpoe

Question 28

EHR software can be designed

Answer 28

Do medically speciality

Question 29

Patient portal

Answer 29

Patient can set their own appointments

Question 30

EHR can tell

Answer 30

If the procedure matches the code

Question 31

Terminally digital file

Answer 31

Numerical