Question 1

The medical record is important to a health care facility because it ___________.

Accepted Answer

A)  is a legal document 
B)  is a record of the care and treatment rendered to caregivers 
C)  is financially unnecessary 
D)  provides a planning tool for patient care 
A)  is a legal document 
B)  is a record of the care and treatment rendered to caregivers 
C)  is financially unnecessary 
D)  provides a planning tool for patient care

Question 2

Progress notes should describe the patient's ___________

Accepted Answer

A)  symptoms or condition being addressed, the treatment rendered, the patient response, and patient's status at the time treatment is discontinued 
B)  treatment rendered but not the patient's response 
C)  patient's status 3 weeks after discharge 
D)  observation of the physician 
A)  symptoms or condition being addressed, the treatment rendered, the patient response, and patient's status at the time treatment is discontinued 
B)  treatment rendered but not the patient's response 
C)  patient's status 3 weeks after discharge 
D)  observation of the physician

Question 3

When making changes to a patient's record, ___________.

Accepted Answer

A)  erasures and correction fluid should be used to cover up entries 
B)  covering up mistakes is not considered tampering. 
C)  a single line should be drawn through a mistaken entry and the correct information should be entered, signed, and dated 
D)  the correction is signed, but the inclusion of a date is unnecessary 
A)  erasures and correction fluid should be used to cover up entries 
B)  covering up mistakes is not considered tampering. 
C)  a single line should be drawn through a mistaken entry and the correct information should be entered, signed, and dated 
D)  the correction is signed, but the inclusion of a date is unnecessary

Question 4

Ownership of the medical record resides with ___________.

Accepted Answer

A)  the provider 
B)  legal counsel 
C)  patient 
D)  physician rendering treatment 
A)  the provider 
B)  legal counsel 
C)  patient 
D)  physician rendering treatment

Question 5

The medical record must be ___________.

Accepted Answer

A)  complete and accurate 
B)  legible and inaccurate 
C)  available solely to those conducting research 
D)  available basically for billing purposes 
A)  complete and accurate 
B)  legible and inaccurate 
C)  available solely to those conducting research 
D)  available basically for billing purposes

Question 6

Falsification of medical records is grounds for a ___________.

Accepted Answer

A)  negligent act 
B)  criminal indictment 
C)  tort 
D)  contract dispute 
A)  negligent act 
B)  criminal indictment 
C)  tort 
D)  contract dispute

Question 7

The integrity and completeness of the medical record can be important in reconstructing the events surrounding an alleged negligence or criminal act in the care of a patient. The medical record can ___________.

Accepted Answer

A)  aid police investigations 
B)  aid in determining the cause of death 
C)  provide information for workers' compensation cases and personal injury proceedings 
D)  all of the above 
A)  aid police investigations 
B)  aid in determining the cause of death 
C)  provide information for workers' compensation cases and personal injury proceedings 
D)  all of the above

The medical record is important to a health care facility because it ___________.

Progress notes should describe the patient's ___________

When making changes to a patient's record, ___________.

Ownership of the medical record resides with ___________.

The medical record must be ___________.

Falsification of medical records is grounds for a ___________.

The integrity and completeness of the medical record can be important in reconstructing the events surrounding an alleged negligence or criminal act in the care of a patient. The medical record can ___________.

Reflections of the Past

Government, Law, and Ethics

Tort Law

Criminal Aspects of Health Care

Contracts

Civil Procedure and Trial Practice

Corporate Structure and Legal Issues

Medical Organization and Physician Liability

Nursing and the Law

Hospital Departments and Allied Health Professionals

Patient Consent

Patient Rights and Responsibilities

Health Care Ethics

Procreation and Ethical Dilemmas

End of Life Issues

Legal Reporting Requirements

Labor Relations

Employment-Atwill and Discharge

Employee Rights and Responsibilities

Professional Liability Insurance

Filters

Exam 11: Medical Records

The medical record is important to a health care facility because it ___________.

Progress notes should describe the patient's ___________

When making changes to a patient's record, ___________.

Ownership of the medical record resides with ___________.

The medical record must be ___________.

Falsification of medical records is grounds for a ___________.

The integrity and completeness of the medical record can be important in reconstructing the events surrounding an alleged negligence or criminal act in the care of a patient. The medical record can ___________.

Reflections of the Past

Government, Law, and Ethics

Tort Law

Criminal Aspects of Health Care

Contracts

Civil Procedure and Trial Practice

Corporate Structure and Legal Issues

Medical Organization and Physician Liability

Nursing and the Law

Hospital Departments and Allied Health Professionals

Patient Consent

Patient Rights and Responsibilities

Health Care Ethics

Procreation and Ethical Dilemmas

End of Life Issues

Legal Reporting Requirements

Labor Relations

Employment-Atwill and Discharge

Employee Rights and Responsibilities

Professional Liability Insurance

Filters