Assume you are in charge of recording medical information in a patient's record after the patient had seen his or her physician. What seven items will you be sure to record?
1) Physicians assessment
2) Diagnosis
3) Recommendations
4) Treatment prescribed
5) Progress notes
6) Instructions given to patient
7) Notate all new prescriptions the physician writes and refills for the patient
What are the five C's for correctly entering information into a medical record?
1) Concise
2) Complete
3) Clear
4) Correct
5) Chronologically ordered
After an entry in the medical record has been written or keyed and an error is discovered, what procedure should be followed to correct the error?
None of these
Which of the following comments should NOT be included in a patient's medical record?
Patient is big as a blimp.
Dr. Wellness works as an employee of Anytown Medical Clinic. Who owns the records of his patients?
Anytown Medical Clinic
Dr. Wellness also sees patients at Anytown General Hospital, where he maintains records of hospital stays, procedures, and emergency room visits. To whom do these records belong?
Anytown General Hospital
Jan B. is a patient of Dr. Wellness, who practices alone. She is moving and wants to transfer her medical records from Dr. Wellness to her new physician, Dr. Good, who works for the Good Samaritan Clinic. Does Jan have the right to obtain copies of her me
Yes, but she must sign a consent form
In the situation in question 7, who owns Jan's medical records before she moves?
Dr. Wellness
Who owns the medical records after Jan moves and begins to see Dr. Good?
The Good Samaritan Clinic
Which of the following is NOT necessary for Jan's medical records to be transferred to her new physician?
Jan's attorney must be present when she signs the request to transfer her records
In a court of law, which one of the following types of testimony will prevail?
The written documentation in a medical record
Medical records are often subpoenaed in court because a patient's medical record is what kind of document?
Legal document
Which of the following statements is NOT true of statute of limitations laws?
All specify that the time period for filing a medical malpractice lawsuit is two years
Which of the following is NOT true of requests for medical records?
A patients complete medical record should always be released on request
What is rule number one if you are correcting an entry in a patient's electronic medical record?
The original record must be maintained
The copier malfunctions while you are photocopying a patients medical records and prints too many copies of several pages. What will you do with the extra copies?
Shred them in a paper shredder
Assume you are in charge of releasing medical records to a third party. Which of the following does NOT require the patients written consent?
Release of the records for use in a lawsuit, in response to a courts subpoena
Which of the following is NOT a threat to the confidentiality of a patient's medical record?
A physician shows a patients medical record to a consulting specialists
Which of the following individuals may not be able to give informed consent for medical treatment?
A person who speaks a foreign language
Health information technology (HIT) includes
All of these
According to the federal government, which of the following is NOT a benefit of HIT with the wide adoption of technology?
Reducing discrimination in health care workplaces
Match each definition 22-27
22) HIPAA
23) Doctrine of informed consent
24) Good Samaritan act
25) Medical record
26) Doctrine of professional discretion
27) Confidentiality of Alcohol and Drug Abuse, Patient Records