Medical Assisting Administrative And Clinical Procedures With Anatomy & Physiology 3rd Edition By Kathryn Booth- Test Bank

65. All medical records are considered the property of the physician; however, the information they contain belong to the patient and are regarded as ________. The patient’s written consent is required to release them.
    confidentialor  
    PHI

Information contained in a patient’s medical record is confidential and is protected under HIPAA.

66. When you are in doubt about who is ________ to give consent to release information, you should ask your supervisor before releasing confidential medical records.
    authorized

If you are in doubt about who is authorized to sign a consent to release medical records, always ask your supervisor before releasing the medical records.

ABHES: 4.b Institute federal and state guidelines when releasing medical records or information
Blooms: Remember
CAAHEP: IX.C.3 Describe the implications of HIPAA for the medical assistant in various medical settings
CAHIIM: III.B.3 Healthcare Privacy, Confidentiality, Legal, and Ethical Issues 3. Release patient-specific data to authorized users.
Est Time: 1-3 minutes
Learning Outcome: 11-07
Level of Difficulty: 1 Easy
Topic: Responding to Release of Records Request

67. A(n) ________ is an examination and review of patient records.
    audit

Auditing involves examining and reviewing a group of patient records for completeness and accuracy.

ABHES: 4.b Institute federal and state guidelines when releasing medical records or information
Blooms: Remember
CAAHEP: IX.C.3 Describe the implications of HIPAA for the medical assistant in various medical settings
CAHIIM: III.B.3 Healthcare Privacy, Confidentiality, Legal, and Ethical Issues 3. Release patient-specific data to authorized users.
Est Time: 1-3 minutes
Learning Outcome: 11-07
Level of Difficulty: 1 Easy
Topic: Responding to Release of Records Request

68. A(n) ________audit is frequently done by a third party if fraudulent billing is suspected.
    external

Government entities, managed care organizations, and private insurance carriers perform external audits to seek to recover possible overpayments.

ABHES: 4.b Institute federal and state guidelines when releasing medical records or information
Blooms: Understand
CAAHEP: IX.C.3 Describe the implications of HIPAA for the medical assistant in various medical settings
CAHIIM: III.B.3 Healthcare Privacy, Confidentiality, Legal, and Ethical Issues 3. Release patient-specific data to authorized users.
Est Time: 1-3 minutes
Learning Outcome: 11-07
Level of Difficulty: 2 Medium
Topic: Responding to Release of Records Request

69. A physical examination form that is used during an “oral examination” to identify any signs or symptoms the patient may be experiencing or reveal information about an illness or condition is called a review of _________ or ROS.
    systems

A review of systems, or ROS, form is used to record the results of an “oral examination” to reveal patient signs and symptoms or other information about an illness or condition.

ABHES: 8.b Prepare and maintain medical records
Blooms: Remember
CAAHEP: V.C.6 Describe various types of content maintained in a patient’s medical record
CAHIIM: I.B.3 Healthcare Information Requirements and Standards 3. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.
Est Time: 1-3 minutes
Learning Outcome: 11-02
Level of Difficulty: 1 Easy
Topic: Contents of Patient Medical Records

70. The section of a patient medical history form that contains the patient’s description of the current condition or complaint is called the _________of present illness section.
    history

The history of present illness section of the medical history form is where the patient is asked to describe the history of the complaint or condition that is the reason for the patient’s visit.

ABHES: 8.b Prepare and maintain medical records
Blooms: Remember
CAAHEP: V.C.6 Describe various types of content maintained in a patient’s medical record
CAHIIM: I.B.3 Healthcare Information Requirements and Standards 3. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.
Est Time: 1-3 minutes
Learning Outcome: 11-02
Level of Difficulty: 1 Easy
Topic: Contents of Patient Medical Records

71. Part of creating timely and accurate records is maintaining a(n) ________ tone in your writing.
    professional

An important part of creating timely and accurate records is maintaining a professional tone in your writing when recording information.

ABHES: 4.a Document accurately
Blooms: Understand
CAAHEP: IX.P.7 Document accurately in the patient record
CAHIIM: I.B.3 Healthcare Information Requirements and Standards 3. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.
Est Time: 1-3 minutes
Learning Outcome: 11-05
Level of Difficulty: 2 Medium
Topic: Appearance, Timelines, and Accuracy of Records

72. Patient X-ray and lab tests should be placed in the medical record according to facility policy, but always in reverse ________ order.
    chronological

Always place X-ray and lab test results in reverse chronological order so that the most current result is always on top.

ABHES: 4.a Document accurately
Blooms: Remember
CAAHEP: IX.P.7 Document accurately in the patient record
CAHIIM: I.B.3 Healthcare Information Requirements and Standards 3. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.
Est Time: 1-3 minutes
Learning Outcome: 11-04
Level of Difficulty: 1 Easy
Topic: Documentation and the 6 Cs of Charting

73. When you release medical information, always send ________ unless the record will be used in a court case, in which case you should send the original records.
    copiesor  
    photocopies

Make photocopies of the requested original material. Never send originals unless the record has been subpoenaed for use in a court case.

ABHES: 4.b Institute federal and state guidelines when releasing medical records or information
Blooms: Remember
CAAHEP: IX.C.3 Describe the implications of HIPAA for the medical assistant in various medical settings
CAHIIM: III.B.3 Healthcare Privacy, Confidentiality, Legal, and Ethical Issues 3. Release patient-specific data to authorized users.
Est Time: 1-3 minutes
Learning Outcome: 11-07
Level of Difficulty: 1 Easy
Topic: Responding to Release of Records Request

74. The specific information required of a population that must be obtained when a new patient makes an appointment with the office is ________.
    demographics

Demographics, or specific information required of a population, must be obtained when a new patient makes an appointment with the office.

ABHES: 8.b Prepare and maintain medical records
Blooms: Remember
CAAHEP: V.C.6 Describe various types of content maintained in a patient’s medical record
CAHIIM: I.B.3 Healthcare Information Requirements and Standards 3. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.
Est Time: 1-3 minutes
Learning Outcome: 11-02
Level of Difficulty: 1 Easy
Topic: Contents of Patient Medical Records

75. The primary problem for which a patient comes to see the physician is known as the ________ complaint.
    chief

The primary problem that is the reason for a patient’s visit is the chief complaint.