Exam 2: The Health Record

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When documents are added to a patient's chart,the most recent information should be placed on top.

(True/False)
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The process of moving an active file to inactive status is called

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A(n)__________ file is a follow-up system used to help the medical assistant remember when a certain task needs to be done.

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Because some physicians' handwriting is illegible,the electronic health record helps guarantee that the documents will be readable even several years after their creation.

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The patient owns the medical record.

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Additional training on the EHR system is needed to run it at full __________.

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An aggregate of activities designed to ensure adequate quality is called quality control.

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The type of electronic record of health-related information about an individual that can be created,gathered,managed,and consulted only by authorized clinicians and staff in a single healthcare organization is a(n)

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By legal definition,if it isn't charted,then it didn't happen.

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The type of electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards and that can be created,managed,and consulted by authorized clinicians and staff from more than one healthcare organization is a(n)

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The medical record should be released only with a

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Which of the following is not an advantage of color-coded filing systems?

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To be granted or endowed with a particular authority or right is to be __________.

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The American Recovery and Reinvestment Act of 2009 is commonly known as the Economic Stimulus Package and was meant to promote economic recovery.

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What is the most important reason for telling the physician when a charting error is discovered later?

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A provisional diagnosis is not a final diagnosis and usually is made before test results are received.

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A standard,nationwide rule must be followed in establishing a records retention schedule.

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Advantages of the EHR system include

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Perhaps the most essential action for the medical assistant working with a patient and using an electronic record is to

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Any of a set of physical properties,the value of which determines characteristics or behavior,is called a(n)__________.

(Short Answer)
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