Chapter 14: The Paper Medical Record Study Guide Answer Keys

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1 Chapter 14: The Paper Medical Record VOCABULARY REVIEW 1. alphanumeric 2. alphabetic 3. numeric 4. tickler 5. augment 6. subjective 7. objective 8. shingling 9. caption 10. audit 11. procrastination 12. vested 13. obliteration 14. provisional diagnosis 15. retention SKILLS AND CONCEPTS Part I: Filing Medical Records 1. Adams, Bentley James 2. Adams, Percevial Butch 3. Beall, Starr Ellen 4. Belk, Riley Americus 5. Brown, Charles Thomas 6. Bruin, Thomas Charles 7. Chapman, Alisha Dawn 8. Chapmann, Karry Madge 9. Conn, Anton Douglas 10. Crumley, LaNelle Elva 11. Frazier, Tamika Noelle 12. Gibson, Mitchel Michael 13. Haile, Sarah Kay 14. Hale, Cassidy Kay 15. Jackson, Taylor Ann Part II: Subjective and Objective Information 1. Subjective 2. Objective 3. Subjective 4. Subjective 5. Objective 16. Kizer, Montana Skye 17. LaRose, Dakota Marie 18. LeGrand, Candace Cassidy 19. Metzger, Robbie Sue 20. Montgomery, Sara Suzelle 21. Murchison, Winston Roger 22. Perez, Randi Ann 23. Raglan, Cecelia Gayle 24. Ragland, Sarah Sue 25. Robison, Lorienda Gaye 26. Santos, Carlos Perez 27. Stuart, Marie Gracelia 28. Turner, George Scott 29. Williams, Alisa Jordan 30. Yarbrough, Allison Gaile 6. Objective 7. Subjective 8. Objective or subjective 9. Objective 10. Subjective Part III: Short Answer 1. a. To assist the physician in providing the best possible medical care for the patient b. To offer legal protection for those who provided care to the patient c. To provide statistical information that is helpful to researchers d. Because they are vital for financial reimbursement

2 Chapter 14: The Paper Medical Record 2. The owner of the physical medical record is the physician or medical facility, often called the maker, that initiated and developed the record. The patient has the right of access to the information within but does not own the physical chart or other documents pertaining to the record. The patient has a vested interest and therefore has the right to demand confidentiality of all of the information placed in the chart. 3. The use of color visually restricts the area of search for a specific record. A misfiled chart is easily spotted even from a distance of several feet. In color-coding, a specific color is selected to identify each letter of the alphabet. The application of the principle may be through using colored folders, adhesive colored identification labels, or various combinations of these. 4. a. Paper-based patient records b. Computer-based patient records 5. Revocation of release of medical records Part V: Changing or Correcting Medical Records 1. Correction: The date above should read XX. P. Smith, RMA XX XX: Patient s complaint of chest pain is of a 2-week duration, not a 2-month duration. R. Smithee, CMA (Corr. R. Smithee, CMA Weeks XX) XX Correction: Date of last refill was written incorrectly in above entry. The actual date of the last refill was XX. Submitted to Dr. Lawton to reconsider refill of medication. S. Ragland, RMA Explain the error to the physician and ask whether he or she wants to refill the patient s medication or advise the patient to schedule a follow-up appointment XX Mr. Robertson cancelled surgical follow-up appt. today. Third cancellation. Refer to Dr. Hughes. S. Ragland, RMA XX Ms. Adams reports she is not better since OV last Monday. Requests Rx refill for antibiotics. Did not RTC on Thursday as directed. States she cannot come to clinic this week. Refer to Dr. Hughes for follow-up. S. Ragland, RMA XX Ms. Smith calls office to report redness around injection site (penicillin, 2:30 PM), itching, difficulty breathing. Refer to emergency department for possible allergic reaction. Requested patient to call office tomorrow to schedule follow-up appointment. S. Ragland, RMA. Part VI: Filing Procedures 1. a. Conditioning: Conditioning of papers involves removing all pins, brads, and paper clips; stapling related papers together; attaching clippings or items smaller than page-size to a regular sheet of paper with rubber cement or tape; and mending damaged records. b. Releasing: Some type of mark is placed on the paper to indicate that it is now ready for filing. This usually is either the medical assistant s initials or a FILE stamp placed in the upper left corner. c. Indexing: Indexing is deciding where to file the letter or paper. This may be done by underlining the name or subject, if it appears on the paper, or writing the indexing subject or name in some conspicuous place. d. Coding: If the paper logically could be filed in more than one place, the original is coded for the main location; a cross-reference sheet then is prepared indicating this location and is coded for the second location. Every paper placed in a patient s chart should have the date and the patient s name on it, usually in the upper right corner. e. Sorting: Arranging the papers in filing sequence.

3 Chapter 15: The Electronic Medical Record VOCABULARY REVIEW 1. aggregate 2. health 3. medical 4. prevalent 5. interoperable 6. computer 7. informatics 8. parameters SKILLS AND CONCEPTS Part I: Electronic Medical Records 1. The five requirements include the following: - The agencies that are involved will implement interoperable systems as their current systems are upgraded (e.g., the Center for Medicare and Medicaid Services). - Providers (e.g., a regional Veterans Administration Hospital) and payers with whom the agencies do business will also implement interoperable systems as their current systems are upgraded. In other words, a hospital that receives federal funding (e.g., Medicare) will have to adopt electronic health record systems. - The prices paid to beneficiaries will be available both to beneficiaries and to enrollees in the health plan. - The agencies and providers will participate in the development of information about the overall cost of healthcare services and treatments. - The agencies and providers will develop and identify, for beneficiaries, enrollees, and providers, approaches that encourage the provision and receipt of high-quality, efficient healthcare. 2. a. Reduces medical errors b. Reduces costs c. Functions with fewer personnel d. Maintains confidentiality e. Saves space 3. a. Cost b. Encouraging employees to learn a new system c. Time to train employees d. Space requirements e. Technologic knowledge requirements (Many additional disadvantages are listed in the text.) Part II: EMR Capabilities 1. Approximately $33,000 Part III: The Patient and the EMR 1. The student should express empathy and explain or demonstrate how the system will keep patient information confidential. The student should allow the patient to ask questions and, if the person wishes, to watch as the patient s information is being entered into the computer. Part IV: Nonverbal Communication and the EMR 1. Maintain good eye contact, looking at the patient more than the computer; sit beside the patient instead of at a desk across from him or her; encourage the patient to watch the input process, if he or she wants to do so; avoid trying to hide the computer screen from the patient s view.

4 Chapter 15: The Electronic Medical Record Part V: Nationwide Health Information Network (NHIN) 1. The Nationwide Health Information Network was developed to provide a secure, national, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting healthcare. The organization is a critical part of the national information technology agenda and will enable health information to follow the consumer, make it available for clinical decision making, and support appropriate use of healthcare information beyond direct patient care so as to improve health. 2. Answers may include the following: - Aid development of capabilities for standards-based, secure data exchange nationwide. - Improve the coordination of care information among hospitals, laboratories, physicians offices, pharmacies, and other providers. - Ensure that appropriate information is available at the time and place of care. - Ensure that consumers health information is secure and confidential. - Give consumers new capabilities for managing and controlling their personal health records, as well as providing access to their health information from electronic health records and other sources. - Reduce risks from medical errors and support the delivery of appropriate, evidencebased medical care. - Lower healthcare costs resulting from inefficiencies, medical errors, and incomplete patient information 3. Students can determine which agencies they feel will be the major players in the conversions of EMR systems and may want to place them in order of importance. Part VI: Backup Systems for the EMR 1. Answers may include the following: - Dedicated servers - High-capacity jump drives - Online backup services - External hard drives

5 Chapter 16: Health Information Management VOCABULARY REVIEW 1. authenticate 2. sentinel event 3. encrypt 4. standards 5. erroneous 6. transpose 7. quality assurance 8. contraindication 9. disparities 10. circumvent 11. adverse 12. near miss SKILLS AND CONCEPTS Part I: Short Answer 1. Health information management is the profession that focuses on healthcare data and the management of healthcare information resources. The profession addresses the nature, structure, and translation of data into usable forms of information for the advancement of health and healthcare of individuals and populations. Health information professionals collect, integrate, and analyze primary and secondary healthcare data; disseminate information; and manage information resources related to research, planning, provision, and evaluation of healthcare services. 2. a. To plan care for patients and ensure that they receive continuity of care from one healthcare provider to another b. To provide statistical information c. To plan the types of services and equipment will be needed to meet the needs of the patient population d. To determine whether claims should be paid e. To determine whether patients are being provided high-quality healthcare. 3. Underuse of medical services means that healthcare services are not being used that might allow diagnosis of disorders, which then could be treated by physicians. Catching such disorders early may lead to reduced costs, as opposed to waiting until a disease has fully progressed, in which case treatment can be extremely expensive. 4. Costs rise when providers overuse medical services, such as ordering excessive, unnecessary healthcare procedures and treatments. Overused treatments and services include hysterectomies, tympanostomy tubes, and antibiotics. Antibiotics are prescribed widely for common colds and acute bronchitis, but the drugs do not benefit patients with these illnesses. 5. Statistics include the following: - Teenage pregnancy - Incidence of human immunodeficiency virus (HIV) infection - Alcohol and drug use - Births - Deaths - Communicable diseases - Infant health and mortality - Leading causes of death - Life expectancy - Sexually transmitted diseases - Suicide

6 Chapter 16: Health Information Management Part II: Characteristics of High-Quality Health Data 1. Completeness 2. Reliability 3. Validity 4. Recognizability 5. Security 6. Legality 7. Accessibility 8. Timeliness 9. Relevance Part III: Acknowledging and Disclosing Medical Errors 1. a. 6 Offer a sincere apology when talking to the patient. b. 3 Call the patient and ask him or her to come to the office. c. 7 Give the patient the opportunity to ask questions. d. 1 Tell the physician about the error. e. 2 Complete an incident report and document the error in the chart. f. 8 Document the discussion of the error with the patient. g. 4 Meet with the patient in a private area where there will be no interruptions. h. 5 Allow the physician to explain the error to the patient. Part IV: Medical Errors 1. An injury caused by medical management rather than the patient s underlying condition. 2. An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. 3. A situation in which an error is caught or corrected before it affects the patient. 4. Answers may include the following: - Fear of litigation - Characteristics of the injury - Physician-patient relationship before the event - Patient s financial status - Patient distress - Patient attrition - Damage to the physician s reputation - License revocation - Loss of facility privileges 5. The physician responsible for the affected patient s care.

7 Chapter 17: Privacy in the Physician s Office VOCABULARY REVIEW 1. provider 2. complainant 3. divulge 4. infer 5. business associate 6. legalese 7. preclude 8. verbiage 9. privacy officer 10. Inspector General 11. Civil Rights 12. due diligence 13. individually identifiable health information 14. protected health information 15. personal health information SKILLS AND CONCEPTS Part I: Health Insurance Portability and Accountability Act 1. a. Patients have more control over their medical records. b. Patients are able to make informed choices regarding how their personal health information is used. c. Boundaries are set on the use and release of health records. d. Safeguards are established that healthcare providers must achieve to protect the privacy of health information. e. Violators are held accountable and face both civil and criminal penalties if patient privacy rights are compromised. f. The Privacy Rule protects public health by striking a balance when public responsibility supports disclosure of personal health information. 2. Title I regulates insurance reform and limits the use of preexisting health conditions that in the past prevented or limited an employee from obtaining health insurance coverage. 3. Title II reduces administrative costs in the healthcare industry and deals with administrative simplification. 4. a. The right to notice of a facility s privacy practices. b. The right to have access to, view, and obtain a copy of their PHI. c. The right to restrict certain parts or uses of their PHI. d. The right to request that communications from the facility be kept confidential. e. The right to request the facility to amend the PHI. f. The right to receive notice of all disclosures of their PHI. 5. a. How PHI is used and disclosed by the facility. b. The provider s duties in protecting health information. c. Patient rights regarding PHI. d. How complaints can be filed if patients believe their privacy has been violated. e. The person to contact at the facility for more information. f. The effective date of the Notice of Privacy Practices.

8 Chapter 17: Privacy in the Physician s Office Part II: Patient s Rights under HIPAA 1. Right to request amendment of protected health information 2. Right to access protected health information 3. Right to request confidential communication 4. Right to notice of privacy practices 5. Right to receive an accounting of disclosures of protected health information 6. Right to request restrictions on certain uses and disclosures of protected health information Part III: Incidental Disclosures 1. Yes 2. Yes 3. Yes 4. Yes Part IV: Notice of Privacy Practices 1. Yes 2. Yes 3. Yes 4. Yes 5. No