Medical Records

Permission grated by an individual voluntarily and in his right mind is known as

consent.

A medical office assistant's family asks to see the medical information of her brother-in-law who has just been brought into the emergency room. If the medical office assistant accesses the information it is

a violation of the Privacy Rule.

Which of the following is the role of a medical transcriptionist in the health care setting?

transforming medical information into a permanent document

In which of the following medical record categories should the medical office assistant file a patient's electrocardiogram result?

diagnostic procedure documents

Which of the following medical reports includes patient demographic information, dates of hospitalization, reason for hospitalization, brief history, significant findings from examinations and tests, course of treatment, final condition of the patient, and final diagnosis?

discharge summary report

A patient with Medicaid presents to the provider's office requesting copies of medical records. The patient presents a valid ID and signs a consent form and the medical office assistant charges the patient $10.00 for the copies. Which of the following is true regarding this charge?

A provider can charge for the medical records because the records belong to the provider.

A patient presents to the outpatient department for a chest x-ray and sputum culture. The patient was referred from his primary care physician for a long-term cough. The resident physician provides the initial interpretation of the x-ray film and states "pneumonia" and signs the report. Seven days later the sputum culture indicates a streptococcal infection. Which of the following actions should the medical office assistant take?

Create an addendum because the new information must be connected to the original note.

The patient who refuses to Pau their medical boll at the established rate after receiving health care services is in breach of which of the following?

contract

which of the following regulates the time frame allowed for filling a lawsuit?

statute of limitations

An adolescent who has been legally granted the status of adulthood and no longer under the care of a parent or guardian is known as which of the following?

emancipated minor

The Needlestick Safety and Prevention Act exists to protect healthcare workers from accidental exposure to

blood borne pathogens.

Which of the following protects a volunteer from liability when providing emergency care in a non-healthcare setting?

Good Samaritan Act

The mutual recognition of a license from one state to another is known as which of the following?

reciprocity

The physician has a public duty to fulfill state reporting requirements in which of the following circumstances involving a patient?

death, stab wound, sexually transmitted infection, elder abuse

Purging is the act of

Moving a file from active to inactive

The medical assistant is contacting a patient to request they make a follow-up appointment. Which of the following forms should the medical assistant verify prior to leaving this message on the patient's voicemail?

HIPAA Confidentiality and Privacy

Which federal regulation requires medical professionals to protect the privacy and confidentiality of patients' health information?

HIPAA

In 1996, Congress passed which of the following statutory laws to ensure that patient information and records will be kept confidential?

HIPAA (Health Insurance Portability and Accountability Act)

A patient calls the office asking for ECG test results. The individual answering the phone should

let the patient know that the results cannot be discussed over the phone.

A phlebotomist's failure to keep any or all privileged medical information private is called

breach of confidentiality.

Which of the following is a characteristic of an EMR system used by a medical office?

It is the principal medical record used in healthcare facilities.