MAST 1060 Final Exam

MAST 1060 Final Exam What is a medical record? - ✔✔A written or electronic record of the important information regarding a paitent. What does a medical record serve as in healthcare? - ✔✔A legal document All informat ...

MAST 1060 Final Exam What is a medical record? - ✔✔A written or electronic record of the important information regarding a paitent. What does a medical record serve as in healthcare? - ✔✔A legal document All information in a medical record is considered what? - ✔✔Confidential What is an EMR? - ✔✔A computerized record Who states that you have to keep patient information confidential? - ✔✔HIPAA What year did HIPAA enforcement begin? - ✔✔2003 What does patient registration record consists of? - ✔✔Demographic and Billing Information What is subjective data? - ✔✔Obtained from the patient What are some subjective symptoms? - ✔✔A symptom that is felt by the patient but is not observable by the examiner. chest pain, cramping, etc. What are some objective symptoms? - ✔✔A symptom that can be observed by an examiner. Swelling, slurred speech, break out, etc. What is a symptom? - ✔✔Any change in the body or its functioning that indicates the presence of disease. What is included in the medical record reports? - ✔✔Health history Physical Examination ECG report Diagnostic Procedure Holter monitor report Spirometry report Radiology report Diagnostic Imaging report Consultation report What is the consent to treatment forms used for? - ✔✔Legal documents required to perform certain procedures or to release information contained in the patient's medical record What does it mean to witness a signature? - ✔✔The MA verified the patient's identity and watched the patient sign the form. What is the release of medical information form? - ✔✔A detailed form that must be completed for requests requiring purposes other than PHI. How will you file a document in reverse chronological order? - ✔✔When the most recent document is placed on top or in front of the other, and the oldest document is on the bottom or at the end of that section. What is SOAP? - ✔✔Subjective data Objective data Assessment Plan When is the health history taken? - ✔✔Before the physician performs the physical examination What is the chief complaint? - ✔✔The symptom causing the patient the most trouble. What is present illness? - ✔✔An expansion of the chief complaint When the MA opens the office, what should he or she do first? - ✔✔Unlock file cabinets, paper medical files, and medicine cabinets How might the MA prepare the telephone system for the day's activities? - ✔✔Notify the answering service that the office is open Which of the following is usually performed by the MA while closing the office? - ✔✔Lock the door through which patients entering the office True or False: When closing the office, some rooms or areas should be locked including the medical record files. - ✔✔True How many folder are in a tickler file? - ✔✔43 What should be attached to the chart for each patient who is going to be seen that day in the office? - ✔✔Charge slip What is required under HIPAA related to the medical office statement of privacy practices? - ✔✔The patient must sign a form acknowledging the opportunity to read or receipt of the office privacy practices. Who is responsible for filling out the charge slip? - ✔✔Physician What is a fixed amount of money that a patient is required to pay each time he or she received treatment? - ✔✔Copayment When is a patient placed in an examination room? - ✔✔After the front office paperwork has been completed What is it called when the medical assistant determines which telephone calls will go to the physician? - ✔✔Screening How do you answer the telephone for the medical office? - ✔✔Promptly Can a MA give test results over the telephone? - ✔✔NO What should the medical assistant determine before placing a call for a physician? - ✔✔If the physician will be ready to talk as soon as the call has been placed. How would a MA handle a call to a doctor from an angry patient? - ✔✔Tell them to write a letter and label it confidential When are appointment reminder calls usually placed to patients? - ✔✔24-48 hours before the appointment Where does the MA record the appointments when a manuel system is used for scheduling? - ✔✔Spiral-bound appointment book Which of the following applies to any manual appointment book? - ✔✔It may be written in pencil to facilitate corrections. What is fixed appointment scheduling? - ✔✔An appointment scheduling method in which each patient is given a specific appointment time What is the name for scheduling patients with similar problems/conditions on certain days? - ✔✔Clustering What is the goal of stream scheduling? - ✔✔To schedule patients so that there is a steady flow of patients moving through the office If an office uses a modified wave scheduling system, how many patients are given individual appointment times? - ✔✔About half of the patients (50%) What is stream scheduling? - ✔✔An appointment scheduling method in which each patient is given a specific appointment time What is double-booking? - ✔✔Scheduling 2 patients for the same appointment time What is clustering? - ✔✔Scheduling similar types of patients for examinations on the same day or part of the day What is modified wave scheduling? - ✔✔An appointment system in which some patients have individual appointment times and some have the same appointment time as other patients. What is time-specified scheduling? - ✔✔An appointment scheduling method in which each patient is given a specific appointment time. What is open hours? - ✔✔Patients may come to the office at any time during the range of hours What is categorization? - ✔✔Scheduling similar types of patients for examinations on the same day or part of the day. What system schedules three or four patients every half hour, who are seen in the order they arrive? - ✔✔Wave How far in advance can patients usually schedule appointments? - ✔✔Up to 6 months What information must be obtained from a new patient? - ✔✔The type of medical insurance and coverage. What is the time allotted for time-specific appointments for a new patient? - ✔✔30-45 minutes What is the time allotted for time-specific appointments for a complete physical examination? - ✔✔30-45 minutes What is the time allotted for time-specific appointments for an established patient? - ✔✔10-20 minutes Which of the following adult patients should be seen by the physician on the day the patient calls, if possible? - ✔✔The patient who complains of nausea and vomiting for the past 3 days. If an unscheduled patient comes to the office but does not appear to be ill, what should the MA do? - ✔✔Explain that the patients are seen with appointments only, and give the patient the first available appointment. How does the office usually handle visits from pharmacy representatives or medical salespeople who want to see the physician? - ✔✔Give them a specific appointment time, often during the lunch break When a patient does not keep an appointment or call to cancel, what should the MA do? - ✔✔Document the missed appointment in the medical record Why is it important to document missed appointments in the patient's medical record? - ✔✔E. All of the above •It shows the patient had an appointment & didn't keep it •Potential defense against a claim that the physician wasn't available •Provides grounds to terminate relationship with patient Why must proper procedures be adhered to in scheduling patients for consultations with specialist? - ✔✔Managed care insurance often requires written referral forms, or it will not pay Why should the office have a system to verify that the results of diagnostic tests were given to the patients? - ✔✔To protect the physician from possible lawsuits for malpractice or abandonment Which of the following info should the MA have on hand before scheduling a diagnostic test for a patient? - ✔✔E. All of the above •Patient's Name & telephone number •Patient's insurance info •Type of procedure •Patient's diagnosis/reason for procedure Which of the following diagnostic tests is usually included in pre admission testing (PAT) before any surgery? - ✔✔Electrocardiogram (ECG) Who is responsible for giving the patient written instructions before surgery? - ✔✔The surgeon's office Which of the following types of medical records may be reviewed to record statistical information? - ✔✔Both paper medical records and electronic medical records What is an outguide? - ✔✔A stiff piece of paper or plastic that is placed in a file when a medical record is removed. Which filing system used for paper medical records protects pt id most successfully? - ✔✔Numeric Using the alphabetic system of filing, what would "The Harris Office Supply Company" be filed under? - ✔✔H If the terminal digit filing system is used, what is the first filing unit for the number 01-68-72- 59? - ✔✔59 What is an indexing unit in alphabetic filing? - ✔✔Each part of a patient's name What is the first indexing unit in alphabetic filing? - ✔✔Last Name What is the second indexing unit in alphabetic filing? - ✔✔First Name What is an advantage of using color-coded labels or folders? - ✔✔It reduces the risk of misfiling If the office is using a color-coded system, who needs to know the meaning of the colors in use? - ✔✔All office staff Which of the following is an indirect method of filing? - ✔✔Numeric Which of the following makes it easier to find a paper medical record that has been removed from the files? - ✔✔Filing out a card to place in the outguide for every record that was removed Why are inactive records removed from the active file area in most offices? - ✔✔To create more space for the records of new pt's Where should the MA's paper tickler files be stored? - ✔✔In a desk or file cabinet near where the MA usually sits In what order are documents filed into a section of the source-oriented medical record? - ✔✔In reverse chronological order (most recent first) How do you use the subject method of filing? - ✔✔Documents may be arranged alphabetically or by the date. It is often used for insurance, bills, research, or other documents related to running the practice rather than the patient records. What must occur before a piece of correspondence can be filed in a patient's paper medical record? - ✔✔It must be initialed by the physician Which of the following is the least common method for backing up the electronic medical record? - ✔✔External hard drive Which of the following statements is true about the margins of a business letter? - ✔✔The top margin should be 2 to 2 1/2 inches What is a standard closing for a business letter? - ✔✔Sincerely, Which is the most formal closing for a business letter? - ✔✔Very Truly Yours, What comes last in a business letter? - ✔✔Referrence Which best describes the spacing in the body of a buisness letter? - ✔✔Single spaced with double space in between paragraphs What are the parts of a business letter? - ✔✔heading, inside address, greeting, body, complimentary close, signature, end notations What punctuation mark follows the complimentary closing of a business letter? - ✔✔Comma Which of the following letters would most likely be signed by the medical assistant? - ✔✔Order for office supplies When the medical assistant answers an email why is it customary to create an answer as a reply? - ✔✔To allow the recipient to read the previous correspondence How many digits are there in a traditional zip code? - ✔✔5 When a letter must reach its destination within 24 hours, how should it be sent? - ✔✔Express Mail The physicians office has a letter weighing 12oz to mail how should this letter be sent? - ✔✔First-Class Mail What classification of mail would most likely be used to send the Journal of Medical Association? - ✔✔Standard Mail What class of mail would cost least if the medical office must mail 2 dvd's? - ✔✔Media Mail Which type of mail is the postage paid by the recipient? - ✔✔Collect on Delivery (COD) How should the Medical Assistant arrange letters or report about the patients for the physician to review? - ✔✔Alphabetically by the patients name What is the primary purpose of a postage meter? - ✔✔To print postage on envelopes or tape strips How does a medical office obtain a postage meter? - ✔✔Rent or lease the meter from an approved vendo Which of the following may pose a safety hazard when using a postage meter? - ✔✔touching one of the moving parts while the machine is operating when is a postage meter more efficient than an online postal service? - ✔✔When office mails large volumes of patient bills weekly How can postage be purchased for a postage meter? - ✔✔By the telephone, using the internet or going to the post office