Chapter 004 Managing Health Information 

Multiple Choice Questions 1. Another name for a central computer is: A. A networkB. File serverC. Hard driveD. Program 2. On-line medical _____ are used to educate physician's concerning conditions and treatment regimes. A. GamesB. CompanionsC. DatabasesD. Courses 3. Most medical billing offices use a medical billing program such as: A. MedicareB. MedisoftC. Medical ManagerD. Medidata 4. Accurate financial records are required for _____ and are critical for the practice's success. A. PurchasingB. BillingC. Tax ReportingD. Balancing 5. One of the most important tasks of an administrative medical assistant is the creation of: A. Health insurance claimsB. Patient dataC. Practice documentsD. Patient accounts 

6. The abbreviation EFT stands for: A. Electronic funds tradeB. Electronic forms tradeC. Electronic forms transferD. Electronic funds transfer 7. _____ computers are the most powerful computers available. A. MiniB. SuperC. MainframeD. Personal 

8. _____ computers are used in large businesses, hospitals, large clinics, and government organizations. A. MainframeB. MiniC. SuperD. Personal 9. _____ computers have less power than mainframes. A. HospitalB. SuperC. PersonalD. Mini 10. To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between ________ away. A. 1 and 1.5 feetB. 2 and 2.5 feetC. 3 and 3.5 feetD. 4 and 4.5 feet 

11. A(n) _____ is a standard version of a document that is used over and over again. A. TemplateB. FormC. StencilD. Sample 12. _____ are assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail. A. LocksB. Log-onsC. PermissionsD. Passwords 13. A patient's medical record constitutes the _____ record of the medical practice. A. EstablishedB. OfficialC. LegalD. Valid 14. Making corrections to a chart with an eraser or scribbling out entries could present the appearance of _______________. A. A mistakeB. An errorC. FraudD. Cheating 

15. If you make an error while recording an entry in the medical record, do all of the following except: A. Write the word "error" next to the errorB. Write your initials next to errorC. Use correction tape to keep the entry neat.D. Write the date next to the error. 

16. Offices using electronic medical record entry methods should affix this to all chart entries: A. A labelB. A validation codeC. An electronic date stampD. Electronic signature 17. A chronological record of ongoing patient care and progress is also known as: A. A chart noteB. A chart planC. Patient noteD. Patient plan 18. What method is the most common system for outlining and structuring chart notes for a medical record? A. CHEDDARB. SOAPC. POMRD. SOMR 19. This charting format breaks down the components of a patient encounter into seven detail-oriented sections: A. CHEDDARB. SOAPC. POMRD. SOMR 20. The _____ findings in a SOAP record are the physician's examination of the patient. A. SubjectiveB. Objective 

21. The _____ findings are the patient's description of the problem or the complaint. A. SubjectiveB. Objective 22. Based on the database and the initial problems of the patient, the physician: A. Makes a diagnosisB. Makes a prognosisC. Begins a course of treatmentD. Defines an outcome 23. All medical records should be kept until: A. The physician retiresB. The practice closesC. The patient diesD. The possibility of a malpractice suit has passed. 

24. When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be: A. ActiveB. ClosedC. InactiveD. Retired 25. What is the best measurement of the quality of care given to a patient? A. The medical recordB. Patient complianceC. The physician's reputationD. Patient cure rate 

26. Patients ____ the right to inspect their medical documentation. A. HaveB. Do not have 27. This type of file pertains to current patients: A. InactiveB. ActiveC. ClosedD. Closed storage 28. This type of file relates to patients who have not seen the physician for six months: A. ActiveB. InactiveC. ClosedD. Closed storage 29. Federal law _____ regulate retention time frames for patient's medical records. A. Does notB. Does 30. All electronically stored records must be kept according to the _____ retention schedule as that for paper records. A. OldB. NewC. SameD. Different 

31. Records that have been closed and those that must be kept permanently are said to be in _____ storage, a storage area separate from the area where active files are kept. A. SecureB. ActiveC. SafeD. Dead 32. Dead storage ________ be easily accessible. A. ShouldB. Should not 

33. In the medical office, how many main types of records are there? A. OneB. TwoC. ThreeD. Four 34. The central responsibility of the physician's practice is: A. Patient serviceB. Patient careC. Preventative visitsD. Patient well being 35. Which type of files are kept in one place? A. DecentralizedB. CentralizedC. DeadD. Open-shelf files 

36. Information of use to only one staff member, such as a physician's correspondence, is stored in a _____ file convenient to the user. A. DecentralizedB. CentralizedC. DeadD. Open-shelf files 37. The need to conserve space in many offices has made _____ files popular. A. CentralizedB. DeadC. DecentralizedD. Open-shelf files 38. Which type of files save time and labor, but sacrifice some security? A. Open-shelf filesB. Decentralized filesC. Dead filesD. Centralized files 39. Which type of files are arranged from front to back? A. Open-shelf filesB. Centralized filesC. Vertical filesD. Centralized files and vertical files 40. Which type of files are arranged from left to right, instead of from front to back? A. Open-shelf filesB. Centralized filesC. Vertical filesD. Lateral files 

41. File folders may be open on how many sides? A. OneB. TwoC. ThreeD. Any of the above 42. How many steps are included in filing? A. FiveB. FourC. TwoD. One 43. _____ is the mental process of selecting the name, title, or classification under which an item will be filed. A. SortingB. StoringC. CodingD. Indexing 44. _____ is the placing of a number, a letter, or an underscore beneath a word to indicate where the document should be filed. A. CodingB. IndexingC. SortingD. Storing 45. What type of file should be consulted daily? A. CentralizedB. TicklerC. DecentralizedD. Cross-reference 

46. How many rules are there for alphabetic filing? A. FourB. SixC. EightD. Ten 47. It is estimated that _____ percent of healthcare facilities and _____ percent of physician practices that have already implemented EHRs. A. 60, 40B. 70, 30C. 80, 50D. 90, 60 48. More than one person can/cannot use the stored data at the same time. A. canB. cannot 

49. Policies and procedures for updating medical personnel and evidence of the training should be placed in the _____. A. Compliance manualB. Personnel manualC. Procedure manualD. Rule manual 50. Until electronic health records are fully implemented into the healthcare system, _____ will be needed. A. Fax machinesB. Temporary personnelC. File clerksD. Scanners 

51. Completely removing electronic data could give the appearance of _____ and is not permissible in many programs. A. CheatingB. LiabilityC. FraudD. Falsehood 52. _____ in medical documentation can lead to a vast array of consequences. A. InformationB. MistakesC. ErrorsD. Mistakes and errors 53. Transcriptionists use _____ to input medical data. A. KeyboardsB. TemplatesC. PencilsD. Pens 54. Which of the following abbreviations means "before meals"? A. a.c.B. b.c.C. p.c.D. b.m. 55. Which of the following abbreviations means "twice per day"? A. qidB. tidC. bidD. qd 

56. Which of the following abbreviations means "after meals"? A. a.c.B. b.c.C. p.c.D. qd 

57. Lyndia works exclusively inputting data into medical records. She seldom takes a break from inputting and works 4 days per week, 10 hours each day. While driving, she notices a change in her distance vision. Choose which of the following she should do to help ease eye strain while working. A. Place her hands and wrists in horizontal alignment.B. Regularly focus on distant objects.C. Place source documents flat beside her computer.D. Frequently rotate her neck and shoulders. 58. Shannon works for a medical practice that uses the first three letters of the patient's last name and the date of birth as the patient numbers. When Shannon was filing medical insurance claims, she noticed that a chart note had been made in the wrong chart. The physician sees twin females, and the chart for the wrong twin had been noted. To correct the error, Shannon should: A. Eliminate the chart note with correction fluid.B. Use a wide, permanent black marker to cross out the chart note.C. Place a straight line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction.D. Place a wavy line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction. 59. When Dr. Crist opened the EHR for her next patient, she was able to quickly view a listing of all patients' current and previously treated medical conditions. Choose which documentation format Dr. Crist uses. A. SOAPB. CHEDDARC. DATABASED. POMR 

60. Choose which of the following is an acceptable chart notation for "as needed": A. q.4hB. p.r.n.C. a.n.D. as ndd  

Fill in the Blank Questions 61. All chart notes must be signed and __________. ________________________________________ 62. A(n) __________ may be used to send or receive information about the patient immediately. ________________________________________ 63. After taking a message regarding a patient's care, the assistant should obtain the __________. ________________________________________ 64. A technology being used in medical and other offices for data input is __________. ________________________________________ 

65. After a patient encounter, the new electronic medical data should be reviewed and __________ for errors. ________________________________________ 

66. Laws have been passed and large sums of money have, and are being invested in the implementation of __________. ________________________________________ 67. Using the ______ system, it is easy to locate misfiled charts. ________________________________________ 68. A book of consecutive numbers indicating the next available number to be assigned, are assigned from an __________. ________________________________________ 

 Chapter 004 Managing Health Information

Multiple Choice QuestionsAnwsers 1. (p. 131) Another name for a central computer is: A. A networkB. File serverC. Hard driveD. ProgramAnother name for a central computer is a file server.  

2. (p. 131) On-line medical _____ are used to educate physician's concerning conditions and treatment regimes. A. GamesB. CompanionsC. DatabasesD. CoursesOn-line medical databases are used to educate physician's concerning conditions and treatment regimes. 

3. (p. 132) Most medical billing offices use a medical billing program such as: A. MedicareB. MedisoftC. Medical ManagerD. MedidataMost medical billing offices use a medical billing program such as Medisoft. 4. (p. 132) Accurate financial records are required for _____ and are critical for the practice's success. A. PurchasingB. BillingC. Tax ReportingD. BalancingAccurate financial records are required for tax reporting and are critical for the practice's success. 

5. (p. 132) One of the most important tasks of an administrative medical assistant is the creation of: A. Health insurance claimsB. Patient dataC. Practice documentsD. Patient accountsOne of the most important tasks of an administrative medical assistant is the creation of health insurance claims. 6. (p. 132) The abbreviation EFT stands for: A. Electronic funds tradeB. Electronic forms tradeC. Electronic forms transferD. Electronic funds transferThe abbreviation EFT stands for electronic funds transfer. 

7. (p. 133) _____ computers are the most powerful computers available. A. MiniB. SuperC. MainframeD. PersonalSupercomputers are the most powerful computers available.  

8. (p. 133) _____ computers are used in large businesses, hospitals, large clinics, and government organizations. A. MainframeB. MiniC. SuperD. PersonalMainframe computers are used in large businesses, hospitals, large clinics, and government organizations. 

9. (p. 134) _____ computers have less power than mainframes. A. HospitalB. SuperC. PersonalD. MiniMini computers have less power than mainframes.  

10. (p. 135) To avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between ________ away. A. 1 and 1.5 feetB. 2 and 2.5 feetC. 3 and 3.5 feetD. 4 and 4.5 feetTo avoid unnecessary neck and eyestrain when using a computer, position the monitor at or below eye level, between 2 and 2.5 feet away. 

11. (p. 136) A(n) _____ is a standard version of a document that is used over and over again. A. TemplateB. FormC. StencilD. SampleA template is a standard version of a document that is used over and over again. 12. (p. 138) _____ are assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail. A. LocksB. Log-onsC. PermissionsD. PasswordsPasswords are assigned to limit the number of individuals who have access to particular computer files and to help users create a computerized audit trail. 

13. (p. 139) A patient's medical record constitutes the _____ record of the medical practice. A. EstablishedB. OfficialC. LegalD. ValidA patient's medical record constitutes the legal record of the medical practice.  

14. (p. 141) Making corrections to a chart with an eraser or scribbling out entries could present the appearance of _______________. A. A mistakeB. An errorC. FraudD. CheatingMaking corrections to a chart with an eraser or scribbling out entries could present the appearance of fraud. 

15. (p. 141) If you make an error while recording an entry in the medical record, do all of the following except: A. Write the word "error" next to the errorB. Write your initials next to errorC. Use correction tape to keep the entry neat.D. Write the date next to the error.If you make an error while recording an entry in the medical record, do not use correction tape to keep the entry neat.  

16. (p. 141) Offices using electronic medical record entry methods should affix this to all chart entries: A. A labelB. A validation codeC. An electronic date stampD. Electronic signatureOffices using electronic medical record entry methods should affix an electronic signature to all chart entries.

17. (p. 149) A chronological record of ongoing patient care and progress is also known as: A. A chart noteB. A chart planC. Patient noteD. Patient planA patient note is a chronological record of ongoing patient care and progress.  18. (p. 142) What method is the most common system for outlining and structuring chart notes for a medical record? A. CHEDDARB. SOAPC. POMRD. SOMRThe SOAP method is the most common system for outlining and structuring chart notes for a medical record. 19. (p. 142) This charting format breaks down the components of a patient encounter into seven detail-oriented sections: A. CHEDDARB. SOAPC. POMRD. SOMRThe SOAP charting format breaks down the components of a patient encounter into seven detail oriented sections. 20. (p. 143) The _____ findings in a SOAP record are the physician's examination of the patient. A. SubjectiveB. ObjectiveThe objective findings in a SOAP record are the physician's examination of the patient. 

 

21. (p. 142) The _____ findings are the patient's description of the problem or the complaint. A. SubjectiveB. ObjectiveThe subjective findings are the patient's description of the problem or the complaint. 

22. (p. 147) Based on the database and the initial problems of the patient, the physician: A. Makes a diagnosisB. Makes a prognosisC. Begins a course of treatmentD. Defines an outcomeBased on the database and the initial problems of the patient, the physician begins a course of treatment.  

23. (p. 147) All medical records should be kept until: A. The physician retiresB. The practice closesC. The patient diesD. The possibility of a malpractice suit has passed.All medical records should be kept until the possibility of a malpractice suit has passed.

24. (p. 147) When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be: A. ActiveB. ClosedC. InactiveD. RetiredWhen a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be closed.

 

25. (p. 149) What is the best measurement of the quality of care given to a patient? A. The medical recordB. Patient complianceC. The physician's reputationD. Patient cure rateThe best measurement of the quality of care given to a patient is the medical record.  

26. (p. 149) Patients ____ the right to inspect their medical documentation. A. HaveB. Do not havePatients have the right to inspect their medical documentation.  

27. (p. 149) This type of file pertains to current patients: A. InactiveB. ActiveC. ClosedD. Closed storageAn active file pertains to current patients.  

28. (p. 149) This type of file relates to patients who have not seen the physician for six months: A. ActiveB. InactiveC. ClosedD. Closed storageAn inactive file relates to patients who have not seen the physician for six months.  29. (p. 150) Federal law _____ regulate retention time frames for patient's medical records. A. Does notB. DoesFederal law does not regulate retention time frames for patient's medical records 

 

30. (p. 151) All electronically stored records must be kept according to the _____ retention schedule as that for paper records. A. OldB. NewC. SameD. DifferentAll electronically stored records must be kept according to the same retention schedule as that for old papers.  

31. (p. 151) Records that have been closed and those that must be kept permanently are said to be in _____ storage, a storage area separate from the area where active files are kept. A. SecureB. ActiveC. SafeD. DeadRecords that have been closed and those that must be kept permanently are said to be in dead storage, or storage separate from the area where active files are kept. 

32. (p. 151) Dead storage ________ be easily accessible. A. ShouldB. Should notDead storage should be easily accessible. 33. (p. 152) In the medical office, how many main types of records are there? A. OneB. TwoC. ThreeD. FourThere are three main types of records in the medical office: patient medical records, correspondence related to healthcare, and practice management records. 

 

34. (p. 152) The central responsibility of the physician's practice is: A. Patient serviceB. Patient careC. Preventative visitsD. Patient well beingThe central responsibility of the physician's practice is patient care. 

35. (p. 152) Which type of files are kept in one place? A. DecentralizedB. CentralizedC. DeadD. Open-shelf filesCentralized files are kept in one place. 

 

36. (p. 152) Information of use to only one staff member, such as a physician's correspondence, is stored in a _____ file convenient to the user. A. DecentralizedB. CentralizedC. DeadD. Open-shelf filesInformation of use to only one staff member, such as a physician's correspondence, is stored in a decentralized file convenient for the user.

37. (p. 153) The need to conserve space in many offices has made _____ files popular. A. CentralizedB. DeadC. DecentralizedD. Open-shelf filesThe need to conserve space in many offices has made open-shelf files popular.  

38. (p. 153) Which type of files save time and labor, but sacrifice some security? A. Open-shelf filesB. Decentralized filesC. Dead filesD. Centralized filesOpen-shelf files save time and labor.  

39. (p. 153) Which type of files are arranged from front to back? A. Open-shelf filesB. Centralized filesC. Vertical filesD. Centralized files and vertical filesCentralized files and vertical files are arranged from front to back. 

40. (p. 153) Which type of files are arranged from left to right, instead of from front to back? A. Open-shelf filesB. Centralized filesC. Vertical filesD. Lateral filesLateral files are arranged from left to right, instead of from front to back.  

41. (p. 154) File folders may be open on how many sides? A. OneB. TwoC. ThreeD. Any of the aboveFile folders may be open on one, two, or three sides.  

42. (p. 156) How many steps are included in filing? A. FiveB. FourC. TwoD. OneFive steps are included in filing. 

43. (p. 156) _____ is the mental process of selecting the name, title, or classification under which an item will be filed. A. SortingB. StoringC. CodingD. IndexingIndexing is the mental process of selecting the name, title, or classification under which an item will be filed. 

 

44. (p. 156) _____ is the placing of a number, a letter, or an underscore beneath a word to indicate where the document should be filed. A. CodingB. IndexingC. SortingD. StoringCoding is the placing of a number, a letter, or an underscore beneath a word to indicate where the document should be filed. 

45. (p. 157) What type of file should be consulted daily? A. CentralizedB. TicklerC. DecentralizedD. Cross-referenceA tickler file should be consulted daily.  

46. (p. 158) How many rules are there for alphabetic filing? A. FourB. SixC. EightD. TenThere are ten rules for alphabetic filing. 

47. (p. 158) It is estimated that _____ percent of healthcare facilities and _____ percent of physician practices that have already implemented EHRs. A. 60, 40B. 70, 30C. 80, 50D. 90, 60It is estimated that 80 percent of healthcare facilities and 50 percent of physician practices that have already implemented EHRs.  

48. (p. 164) More than one person can/cannot use the stored data at the same time. A. canB. cannotMore than one person can use the stored data at the same time.

 

49. (p. 166) Policies and procedures for updating medical personnel and evidence of the training should be placed in the _____. A. Compliance manualB. Personnel manualC. Procedure manualD. Rule manualPolicies and procedures for updating medical personnel and evidence of the training should be placed in the compliance manual. 50. (p. 167) Until electronic health records are fully implemented into the healthcare system, _____ will be needed. A. Fax machinesB. Temporary personnelC. File clerksD. ScannersUntil electronic health records are fully implemented into the healthcare system, scanners will be needed. 

51. (p. 167) Completely removing electronic data could give the appearance of _____ and is not permissible in many programs. A. CheatingB. LiabilityC. FraudD. FalsehoodCompletely removing electronic data could give the appearance of fraud and is not permissible in many programs. 52. (p. 168) _____ in medical documentation can lead to a vast array of consequences. A. InformationB. MistakesC. ErrorsD. Mistakes and errorsMistakes and errors in medical documentation can lead to a vast array of consequences. 

53. (p. 168) Transcriptionists use _____ to input medical data. A. KeyboardsB. TemplatesC. PencilsD. Pens

Transcriptionists use templates to input medical data.  

54. (p. 167) Which of the following abbreviations means "before meals"? A. a.c.B. b.c.C. p.c.D. b.m.The abbreviation a.c. means "before meals".  

55. (p. 167) Which of the following abbreviations means "twice per day"? A. qidB. tidC. bidD. qdThe abbreviation bid means "twice per day". 

56. (p. 167) Which of the following abbreviations means "after meals"? A. a.c.B. b.c.C. p.c.D. qdThe abbreviation p.c. means "after meals". 57. (p. 128) Lyndia works exclusively inputting data into medical records. She seldom takes a break from inputting and works 4 days per week, 10 hours each day. While driving, she notices a change in her distance vision. Choose which of the following she should do to help ease eye strain while working. A. Place her hands and wrists in horizontal alignment.B. Regularly focus on distant objects.C. Place source documents flat beside her computer.D. Frequently rotate her neck and shoulders.Lyndia should regularly focus on distant objects to help ease eye strain while working. 

58. (p. 139) Shannon works for a medical practice that uses the first three letters of the patient's last name and the date of birth as the patient numbers. When Shannon was filing medical insurance claims, she noticed that a chart note had been made in the wrong chart. The physician sees twin females, and the chart for the wrong twin had been noted. To correct the error, Shannon should: A. Eliminate the chart note with correction fluid.B. Use a wide, permanent black marker to cross out the chart note.C. Place a straight line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction.D. Place a wavy line through the entry, making sure it is still legible; mark it "error"; date her correction; and initial the correction.To correct the error, Shannon should place a straight line through the entry, making sure it is still legible; mark it "error", date her correction; and initial the correction. 

 

59. (p. 145) When Dr. Crist opened the EHR for her next patient, she was able to quickly view a listing of all patients' current and previously treated medical conditions. Choose which documentation format Dr. Crist uses. A. SOAPB. CHEDDARC. DATABASED. POMRDr. Crist used the CHEDDAR format. 

60. (p. 166) Choose which of the following is an acceptable chart notation for "as needed": A. q.4hB. p.r.n.C. a.n.D. as nddThe acceptable chart notation for as needed is "p.r.n." 

Fill in the Blank Questions 61. (p. 101) All chart notes must be signed and __________. DatedAll chart notes must be signed and dated. 62. (p. 101) A(n) __________ may be used to send or receive information about the patient immediately. Fax machineA fax machine may be used to send or receive information about the patient immediately. 

63. (p. 94) After taking a message regarding a patient's care, the assistant should obtain the __________. Patient's chart.After taking a message regarding a patient's care, the assistant should obtain the patient's chart. 64. (p. 169) A technology being used in medical and other offices for data input is __________. Voice Recognition TechnologyA technology being used in medical and other offices for data input is voice recognition technology. 

65. (p. 166) After a patient encounter, the new electronic medical data should be reviewed and __________ for errors. ProofreadAfter a patient encounter, the new electronic medical data should be reviewed and proofread for error. 

66. (p. 164) Laws have been passed and large sums of money have, and are being invested in the implementation of __________. Healthcare reformLaws have been passed and large sums of money have, and are being invested in the implementation of healthcare reform.

 

67. (p. 162) Using the ______ system, it is easy to locate misfiled charts. Color codingUsing the color coding system is easy to locate misfiled charts. 

 

68. (p. 161) A book of consecutive numbers indicating the next available number to be assigned, are assigned from an __________. Accession bookA book of consecutive numbers indicating the next available number to be assigned, are assigned from an accession book.