Question 1

The disadvantage of chronological documentation is

Accepted Answer

A)   subjective data may be missing.
B)   objective data may be missing.
C)   medical problems may go undiscovered.
D)   vital signs are not done. C

Question 2

Computerized medical records

Accepted Answer

A)   pose problems of confidentiality.
B)   make record maintenance and retrieval more efficient.
C)   should be accessed on a need-to-know basis.
D)   all of the above. D

Question 3

A written order requiring a person to appear in court, give testimony, and bring the records described is called

Accepted Answer

A)   res ipsa loquitur.
B)   subpoena duces tecum. question b add subpoena before duces tecum. (word subpoena should not have italics) 
C)   respondeat superior.
D)   a subpoena. B

Question 4

Immunization records should be kept

Accepted Answer

A)   for 10 years.
B)   permanently.
C)   for 5 years.
D)   until the age of maturity.

Question 5

The purpose of a medical record is to

Accepted Answer

A)   provide the billing record of the patient from admission to the practice.
B)   provide the medical picture and record of the patient from birth to death.
C)   provide data and statistics on health matters.
D)   b and c.

Question 6

Federal reimbursement guidelines require that all medical records be completed within

Accepted Answer

A)   15 days following the patient's discharge from a hospital.
B)   30 days following the patient's discharge from a hospital.
C)   45 days following the patient's discharge from a hospital.
D)   60 days following the patient's discharge from a hospital.

Question 7

Patient information in the medical record should include

Accepted Answer

A)   the date of birth.
B)   the date of marriage.
C)   a record of divorces.
D)   the date of the spouse's birth.

Question 8

A medical record ordered by the court to be available during a malpractice case is

Accepted Answer

A)   disclosed.
B)   subpoenaed.
C)   disclosed only to the judge.
D)   disclosed only to the jury.

Question 9

Physicians who wish to disclose confidential medical record information should

Accepted Answer

A)   first discuss it with the patient's family.
B)   discuss it with the patient first.
C)   discuss the risks involved with his or her lawyer.
D)   first discuss the problem with the patient's contact person.

Question 10

To protect patient confidentiality, medical records can be released

Accepted Answer

A)   to an attorney.
B)   to a judge.
C)   to the patient's family members.
D)   only with the patient's written consent.

Question 11

An incomplete medical record may

Accepted Answer

A)   not be a problem, as the remainder of the entry could be discussed during a court hearing.
B)   make it impossible for the healthcare provider to defend allegations in court.
C)   allow only part of a bill to be paid.
D)   not be able to be subpoenaed to court.

Question 12

Confidential medical record information that can be disclosed to a health department without the patient's consent includes

Accepted Answer

A)   HIV cases.
B)   AIDS cases.
C)   abortions.
D)   a and b.

Question 13

Healthcare providers and healthcare institutions who disclose confidential health information may

Accepted Answer

A)   do so without consequences.
B)   face civil or criminal liability for disclosure.
C)   face civil liability for disclosure.
D)   face criminal liability for disclosure.

Question 14

The Privacy Act of 1974 protects private citizens from distribution of information about themselves by the federal government except for that which is received from

Accepted Answer

A)   hospitals.
B)   Veterans Administration hospitals.
C)   privately owned clinics.
D)   Medicare or Medicaid.

Question 15

Older records of former patients

Accepted Answer

A)   need to be kept in the physician's office indefinitely.
B)   can be stored in a clean, dry storage space.
C)   can be destroyed after 5 years.
D)   need to be kept in the physician's office for at least 7 years.

Question 16

All medical records should be stored for

Accepted Answer

A)   5 years from the date of the last entry.
B)   7 years from the date of the last entry.
C)   10 years from the date of the last entry.
D)   23 years from the date of the last entry.

Question 17

Ownership of the medical record usually remains with the

Accepted Answer

A)   physician.
B)   patient.
C)   court.
D)   all of the above.

Question 18

The accepted method of correcting medical record errors is

Accepted Answer

A)   erase and write the correction.
B)   draw a line through the error and write the correction underneath.
C)   draw a line through the error and write the correction above with the date and initials of the person making the correction.
D)   erase and write the correction, adding the date and initials of the person making the correction.

Question 19

A subpoenaed medical record should alert the medical staff that

Accepted Answer

A)   the physician and the patient are to be told that a subpoena has been served.
B)   the physician's attorney should be notified of the subpoena being received.
C)   the records must be turned over to the judge on the specified date.
D)   all of the above.

Question 20

For the court's purpose, if documentation does not appear in the medical record,

Accepted Answer

A)   it did not occur.
B)   it can be documented at a later date without harm.
C)   the court will not use the medical record against the healthcare provider.
D)   all of the above.

Exam 9: The Medical Record