According to the standards of Joint Commission, what is the deadline for completion of a physical examination report on an inpatient?
24 hours
State at least four skills that a successful transcriptionist should have:
a. Has excellent word processing
b. Has knowledge of medical transcription guidelines and practices
c. Has excellent spelling, editing, and proofreading
d. Has a good command English grammar
In transcribing, what is even more important that speed?
Accuracy
Written or typed information set down for the purpose of preserving memory that authenticates evidence of facts and events is a/an:
Medical Records
Briefly list three main purposes of medical records:
a. Help physician in the treatment of patient and future research
b. Practice legal standards
c. Follow the joint commission
Who owns the patient's medical records?
Physician, corporation, or institution
Name two classifications of information contained in medical records:
a. Name and address of person
b. Social security
Name the federal entity that provides specific guidelines for patient privacy:
HIPAA (Health Insurance Portability & Accountability Act)
How would you alert the document author if you found a critical error or discrepancy in a dictation?
Let that person know and find out why they are wrong
If your state has laws protecting patient confidentiality that are stricter than the federal guidelines, to which do you conform?
The State
Is the risk manager responsible for patients, visitors, or employees of a facility?
Employees
What is the main hazard in using the Internet for research?
Be careful to use accurate and valid websites for research
What, if any, is the value of becoming a CMT (certified medical transcriptionist) or RMT (registered medical transcriptionist)?
To be recognize as a profession
When may you disclose protected health information?
Written consent from the patient
What is an advanced directive?
...
The transcriptionist recognized the name of a patient as that of the son of a friend of hers. The report indicated a good prognosis for the child. Because the mother had been depressed and uneasy for her child, the transcriptionist felt it was all right t
...
Name one main difference between a job and a career.
A job is a stepping stone to a lifelong career
At this point, which area of medical transcription appears the most interesting to you?
...
If a surgeon dictates the operative report before the time of surgery, it is:
a. None of the transcriptionist's business
b. A matter for utilization review
c. Discussed with risk management
d. Pointed out to the surgeon
c. Discussed with risk management
In which of the following instances can the medical records of a patient be released to a third party without the patient's written permission?
a. Under no circumstances
b. With a subpoena duces tecum
c. Upon request of the police or prison officials
d. O
d. On the hospital administrator's authority only
Your aunt is visiting and complains to you that she cannot get her physician to return her phone calls and she desperately wants to know if her recent biopsy finding is positive or negative. What would you do?
Tell her to relax and find out what is going on with the doctor
Your hospital administrator was just admitted to an inpatient facility in a nearby community. He has not been at work for more than two weeks and no one knows where he is or what is wrong with him. You know because you have a part-time job transcribing fo
...
If you work as an "independent" contractor doing medical transcription, you become exempt from the HIPAA privacy restrictions. T___F___
False
One would not consider it a breach of HIPAA if you completed your medical transcription from your home. T___F___
True
Where are electronic medical records stored?
a. In the transcriptionist's computer
b. In the dictator's computer
c. On the Internet
d. In the computer where they were downloaded
e. None of the above
c. On the Internet
When you have successfully delivered your transcript, your downloaded files and paper files should be
a. Kept indefinitely
b. Shredded or purged from your equipment
c. Converted into an electronic file
d. Mailed to a secure repository
c. Converted into an electronic file
There is an "unwritten rule" in medicine that if you did not document it
Did not happen
A signed confidentiality statement should be
a. Attached to every patient's records
b. Attached to every employee's personnel records
c. Displayed in the office of each care provider
d. Included as part of every contract for services
...
Turn-around-time (TAT) concerns
a. Your billing for the transcript
b. Security of the medical record
c. Conforming to HIPAA regulations.
d. Joint Commission regulations
d. Joint Commission regulations
What does the reimbursement chain refer to?
a. The fact that documents you transcribe generate revenue.
b. Your payment for transcription based on lines transcribed or the visible black character (VBC).
c. The encryption of the medical record for billing.
d. A report being returned for authentication.