medical Records
What are 3 things that a patient need to give when checking in for an appt.
Name, DOB, Insurance card
Name 4 benefits of EHR
continuity between providers, time efficiency, reduce errors, premade pt. instructions, premade medication information sheets, billing, out-of-work (or school forms), etc...
What is the difference between EMR and EHR
EMR is single office use computer system; EHR is a universal electronic system used by multiple places
What is the insurance for veterans in the US
TRICARE
Claim
Procedure, test, medication submission to have the office/providers be paid for service provided.
Name two disadvantages of paper charts
take up space, one-person use, time consuming, etc...
This type of medical record system organizes patient data by diagnosis
Problem oriented medical record
Who is in charge of CMS?
US Department of Health and Human Services (will accept U.S. Government)
Name 2 items that would go in the "consult" section of a chart.
specialist appts, PT notes, dietician consult notes, any outside providers, etc...
Deductible
Amount patient is responsible in a year before insurance covers payment
This intake questionnaire done by MA collects details about a patient's past surgeries, family medical background, lifestyle habits, and current symptoms.
What is the Medical History Form
If filing reverse chronologic order, which of the following is in the correct order sequence. Paperwork from April 2026 and June 2026
Office visit entries from June 2026 would be in front of visits from April 2026
Name one benefit of a paper chart
inexpensive, file system of your choice, easier to maintain and train on
What is the retention schedule for a medical record?
Encryption
Converting electronic records, data into codes to prevent unauthorized access
Why is faxing used still in the Healthcare field
It is secure
What is the proper procedure to correct an error in a patient's chart paper chart.
One single line through error, write error, date and initial
What are 3 things a patient can do in a patient portal?
Request appt, request med refill, look at labs, look at appts, see diagnoses, etc...
To comply with HIPAA security standards, paper files containing must be secured behind a minimum of this many locking barriers
Two locks
Co-insurance
a second insurance with the primary insurance
What is the most common filing system in paper charts?
They should be labeled with patient's three letters of last name (sometimes first initial added too) and the year on the top
What does CPOE stand for
computerized provider order entry
Name 3 legal (example rights) pieces for the patient reguarding their medical record
Right to authorize release, right to access, ability to correct errors, request copies
What is the period of retention for the following: retirement of a patient's physician?
Records should be transferred to each patient’s new doctor.
Subscriber
Person who has the insurance (i.e through his or her employer)