1
Which of the following would apply to the legal standard if there is no written record of a temperature, a visit, a history, a physical, or a lab report?
It was not written down, so it did not happen.
The court will take the patient’s word for it.
The court will take the provider’s word for it.
The court will make the decision as to whether or not it happened.
It was not written down, so it did not happen.
The middle pair of digits in the middle-digit filing system are considered which of the following?
None of the above
Primary
Third
Secondary
Primary
Which of the following is NOT essential equipment needed with a numeric filing system?
Outguide
Which of the following is used in numeric filing as a journal or computer listing in which numbers are preassigned?
Serial file
Consecutive file
Alphabetic card file
Accession record
Accession record
Which of the following statements does NOT best describe the importance of accurate medical records?
They maintain a conscientious record of patient care.
They are needed to provide referrals.
They assist in controlling the costs of medical care.
They are essential to patient care.
They may be released without a patient’s knowledge.
They may be released without a patient’s knowledge.
What is the most common document that will be a part of the patient chart?
All of the above
Correspondence
Lab reports
Clinical notes
All of the above
Which of the following is NOT an appropriate action to locate missing files?
Check all outguides.
Which of the following best describes how titles are considered when alphabetizing and assigning units for filing order?
Part of the last name
Separate unit at the end
Not a unit
First unit
Separate unit at the end
Which of the following is the appropriate place for filing an item that does not have enough in number to warrant an individual folder?
Incoming correspondence
Dead letter
Miscellaneous
Outgoing correspondence
Miscellaneous
Which of the following is the most appropriate format for a patient’s name on a medical chart?
Nickname
Legal name
Last name, first name
Abbreviation
Legal name
Which of the following is considered primary information found on an outguide?
Which of the following is the correct order of the procedural steps for filing patients’ medical records?
1. Sort
2. Code
3. Inspect
4. Index
5. File
1, 2, 3, 4, 5
4, 3, 1, 2, 5
3, 4, 2, 1, 5
3, 2, 1, 4, 5
3, 4, 1, 2, 5
3, 4, 2, 1, 5
Which of the following filing systems would be most appropriate when you have a large number of patients?
Subject
Numeric
Alphabetic
Geographic
Numeric
Which type of medical record has data filed strictly with the most recently charted materials at the top of the folder?
Source-oriented medical record (SOMR)
Strict chronological arrangement
Problem-oriented medical record (POMR)
SOAP
Strict chronological arrangement
How would Henry Patrick Hays IV be filed in relation to Henry Patrick Hays Jr.?
Depends on the birthdays
Before
After
By address to separate
Before
Which of the following is considered a disadvantage of electronic medical records?
When using a tickler file, what should be listed on the reminder?
All of the above
Required action
Tickler date
Patient name
All of the above
Which of the following best describes records that need to be readily accessible for retrieval of information?
Inactive
Cross-referenced
Closed
Active
Active
Which of the following is the appropriate indexing unit for St. Ann’s Hospital?
Saintanns Hospital
St. Ann’s Hospital
Saint Anns Hospital
Stanns Hospital
Stanns Hospital
Which of the following is NOT considered when choosing a patient filing system?
Amount of cross-referencing needed
Confidentiality
Number of expected patients
Primary filing objectives
Amount of cross-referencing needed
Which of the following medical record formats does NOT contain a problem list?
SOAPER
SOAP
POMR
SOMR
SOMR
The management of the medical record must:
All of the above
There are how many Rules to be followed when filing a patient's chart?
5
9
8
4
9
Which of the following best describes the tab-alpha system?
Combination of 13 colors
Full-cut folders and a color-coded label
Lateral moveable files
Ten colors and 1/3-cut folders
Full-cut folders and a color-coded label
When traditional paper-based charts are used, HIPAA compliance mandates no identifiable patient information should be located on the outside of the chart. This information includes all of the following except:
All of the above information should not be placed on the outside of the chart
Address
Social security number
Date of birth
All of the above information should not be placed on the outside of the chart