Answers to Medical Office Quiz Lesson 1
Answers to Medical Records Quiz Lesson 1
1. Microfilming: Photographic process that reduces a document to a very small size. Types: Roll Film, Cartridges and cassettes, Microfilm jackets, Microfiche, Computer output microfilm, Computer assisted retrieval.
Optical Disk Storage: Uses a laser to etch data onto a permanent surface such as prepared glass and can store a vast amount of paper information on a single disk.
Computerized Patient Record: Entire record, all documentation will be kept on a computer.
2. Joint Commission on Accreditation of Healthcare Organizations-Accredits hospitals based on medical records. Audits every 3 years. Hospitals must be accredited to accept Medicare patients.
3.
Create-upon completion of the face sheet-create the medical record. Face sheet and copy of insurance card on left and blank progress notes on right side.
Use-For patient documentation of diagnosis, treatment, etc. Legal document.
Store-Usually by number.
Retrieve-MPI for patient’s name then use as a cross-reference tool to pull by number.
Destroy-Can not destroy until 10 years inactive use. Then destroy by Burning or Shredding
4. Alphabetic and Numeric
5. Legal Document-To stand up in a court of law showing treatment, procedures and diagnosis.
Patient Care-documentation of patient’s past and present medical history, allergies, etc. to ensure appropriate patient care.
Statistical Information-Used to track trends, planning for hospital growth and staff needs.
6.
Pick up discharge records for each nursing station, clinics, emergency room, outpatient surgery and other departments.
Verify correct number of records and names with the discharge list from the admitting dept., the computer-generated discharge list, or the registration list.
Pull registration forms, MPI cards, file folders from their respective
in-house section, if admission processing is done.
Stamp the discharge date on the original registration form in the record, the registration form copy, and the MPI card. This step is necessary only for inpatients.
Place each record in its folder.
Count folders and registration forms and verify all records have been picked up.
File registration forms in current month folder.
File back MPI cards alphabetically.
Attach loose documents to the records.
File records in alphabetical order behind the file guide pertaining to the discharge date, in the “Records to Be Coded” section.
7. FOIA-Freedom of Information Act-Provides for access to government records.
8. MPI-Master Patient Index
9. Privacy Act of 1974-Provides regulations regarding confidentiality of records maintained on individuals.
10. Inpatient-patient record becomes to thick it may be thinned. Thin oldest forms, progress notes and orders. The thinned records are kept at the nursing station or in the Medical Records Dept. until the inpatient is discharge. Dictated reports and face sheet will never be thinned.
11. Used for readmitted patient to facilitate completion of the record and reduce the amount of space necessary for filing incomplete record. When using temporary records, each individual hospitalization is filed in the permanent file folder only when it is complete.
12. Since outpatients stay in the hospital less than 24 hours, the file folder can be created at the time the record is received in the department rather than at the time of admission. In the outpatient record the emergency room visits, are filed on the left side of the file folder so as to remain separate from the inpatient admissions. It is important to check for loose documents when assembling the record prior to coding.
13. Outguide
14. The Patient
15. Lateral File Cabinet
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