Question 1

Which of the following is considered by some experts to be the most serious problem with electronic health records?

Accepted Answer

A)  Patients don't trust 
B)  Cost of implementation 
C)  Cyberthreats 
D)  Difficulty training staff 
A)  Patients don't trust 
B)  Cost of implementation 
C)  Cyberthreats 
D)  Difficulty training staff

Question 2

Medical records are legal documents that can be used as evidence in court.

Accepted Answer

A) True 
 B)False

Question 3

The federal government provided funds health care providers who accepted Medicare and Medicaid patients to set up electronic medical record systems.

Accepted Answer

A) True 
 B)False

Question 4

A major difficulty with electronic medical records is the inability of the systems from different manufacturers to communicate and share information.

Accepted Answer

A) True 
 B)False

Question 5

Which method of organization describes the source-oriented approach to medical recordkeeping?

Accepted Answer

A)  Chronological order 
B)  By health care specialty 
C)  By the type of health problem 
D)  By the body system affected 
A)  Chronological order 
B)  By health care specialty 
C)  By the type of health problem 
D)  By the body system affected

Question 6

Which of the following is the best definition of charting?

Accepted Answer

A)  Forms a complete chronological health history of a particular patient 
B)  Collection of all documents that are filed together 
C)  Provides legal protection 
D)  Records observations and information about patients 
A)  Forms a complete chronological health history of a particular patient 
B)  Collection of all documents that are filed together 
C)  Provides legal protection 
D)  Records observations and information about patients

Question 7

Which of the following is a purpose for medical documentation?

Accepted Answer

A)  Prevents malpractice lawsuits 
B)  Prevents cost overruns 
C)  Communicates directly with the patient 
D)  Helps ensure compliance with regulatory agencies 
A)  Prevents malpractice lawsuits 
B)  Prevents cost overruns 
C)  Communicates directly with the patient 
D)  Helps ensure compliance with regulatory agencies

Question 8

A major component of HIPAA is to:

Accepted Answer

A)  ensure that Medicare patients receive proper care. 
B)  protect the privacy of patient records. 
C)  control health care costs. 
D)  provide guidelines for patient safety. 
A)  ensure that Medicare patients receive proper care. 
B)  protect the privacy of patient records. 
C)  control health care costs. 
D)  provide guidelines for patient safety.

Question 9

Incomplete documentation can result in denial of payment to health providers by insurance companies.

Accepted Answer

A) True 
 B)False

Question 10

Which is the correct way to document a patient's statement about symptoms experienced?

Accepted Answer

A)  Write direct quotes and enclose the entry in quotation marks. 
B)  Write the statement in your own words. 
C)  Note the statement in a shortened form, using standard abbreviations. 
D)  List the symptoms, using correct medical terminology. 
A)  Write direct quotes and enclose the entry in quotation marks. 
B)  Write the statement in your own words. 
C)  Note the statement in a shortened form, using standard abbreviations. 
D)  List the symptoms, using correct medical terminology.

Question 11

Match between columns
                        Premises: Collection of documents that forms the complete health history of a patient

Accepted Answer

The Answer of Chief complaint and Medical documentation and Assessment is...

Question 12

The health care professional can help protect patient privacy by using a strong computer _____, changing it regularly, and never giving it to anyone.

Accepted Answer

The answer of The health care professional can help protect...

Question 13

Medical charting should be done in pencil because mistakes can be more easily and neatly corrected.

Accepted Answer

A) True 
 B)False

Question 14

Which of the following items would be part of the familial history?

Accepted Answer

A)  Assessment of body systems 
B)  Medical problems of relatives 
C)  Frequency of alcohol use 
D)  Past surgeries of patient 
A)  Assessment of body systems 
B)  Medical problems of relatives 
C)  Frequency of alcohol use 
D)  Past surgeries of patient

Question 15

Match between columns
                        Premises: Recording observations and information about patients

Accepted Answer

The Answer of Charting and Medical record and Assessment and is...

Question 16

A medical record refers to the collection of all documents that are filed together and form a complete chronological health history of a particular patient.

Accepted Answer

A) True 
 B)False

Question 17

Every entry on a medical record must include the time, date, and ________________ of the health care professional who made the entry.

Accepted Answer

The answer of Every entry on a medical record must...

Question 18

Medical documentation refers to notes and documents that health care workers add to the medical record.

Accepted Answer

A) True 
 B)False

Question 19

The physician's orders are the primary tool used to record, communicate, and coordinate the care given to the patient.

Accepted Answer

A) True 
 B)False

Question 20

How should the health care professional select appropriate abbreviations to use in written documentation?

Accepted Answer

A)  Create personal abbreviations that are clear. 
B)  Refer to a standard medical dictionary. 
C)  Use those learned in medical terminology courses. 
D)  Follow facility policies. 
A)  Create personal abbreviations that are clear. 
B)  Refer to a standard medical dictionary. 
C)  Use those learned in medical terminology courses. 
D)  Follow facility policies.

Exam 19: Documentation and Medical Records

Which of the following is considered by some experts to be the most serious problem with electronic health records?

Medical records are legal documents that can be used as evidence in court.

The federal government provided funds health care providers who accepted Medicare and Medicaid patients to set up electronic medical record systems.

A major difficulty with electronic medical records is the inability of the systems from different manufacturers to communicate and share information.

Which method of organization describes the source-oriented approach to medical recordkeeping?

Which of the following is the best definition of charting?

Which of the following is a purpose for medical documentation?

A major component of HIPAA is to:

Incomplete documentation can result in denial of payment to health providers by insurance companies.

Which is the correct way to document a patient's statement about symptoms experienced?

The health care professional can help protect patient privacy by using a strong computer _____, changing it regularly, and never giving it to anyone.

Medical charting should be done in pencil because mistakes can be more easily and neatly corrected.

Which of the following items would be part of the familial history?

A medical record refers to the collection of all documents that are filed together and form a complete chronological health history of a particular patient.

Every entry on a medical record must include the time, date, and ________________ of the health care professional who made the entry.

Medical documentation refers to notes and documents that health care workers add to the medical record.

The physician's orders are the primary tool used to record, communicate, and coordinate the care given to the patient.

How should the health care professional select appropriate abbreviations to use in written documentation?

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