Ellen is preparing a new paper-based medical record for a patient whose name is Michael T. van Allen. What two letters should she affix to the medical record?
AL
MI
MV
VA
What does Ellen consider the primary reason for using color-coded letter labels on paper-based medical records?
To protect patient confidentiality
To distinguish between records of patients with similar names
To reduce the risk of filing records incorrectly
To distinguish between the patients of different physicians
When Ellen removes paper-based medical records from the files for patients to be seen the following day, what does she place in the file where the record is normally stored?
Nothing
Outguide
Tab divider
Plain manila folder
Ellen is arranging paper-based medical records for filing. Which of the following records would be filed first?
Jones, Amy L.
Jones, Louise
Johnson, Amy L.
Jones, K.W.
If Ellen is preparing a paper-based medical record for a new patient, which of the following supplies or equipment will not be required?
Stapler
Name label
Two-hole punch
Set of medical record dividers
If Ellen’s office removes inactive paper-based records to separate storage when the patient has not been seen for more than 3 years, records with labels for which of the following years will be removed at the end of 2016?
2014
2015
Both 2014 and 2015
Neither 2014 or 2015
When Ellen is sorting reports to place in the paper-based medical records, what should she check for?
Patient name on the report
Physician initials
Date of service
Official hospital seal
When selecting a storage area for inactive paper-based medical records, which of the following factors should Ellen be most concerned with?
Control of relative humidity
Presence of at least two windows
Temperature above 74 °F
At least five feet of space between all shelving units
Ellen also uses the alphabetic method to file business correspondence. Under which letter would she file correspondence from The Harris Office Supply Company?
C
H
O
T
Which of the following filing methods would be most useful for Ellen to file folders containing instructional brochures for patients?
Numeric
Subject
Chronological
Geographic
A medical record is a written document of the important information regarding a patient.
The medical record includes the patient’s health history, treatment, and progress notes.
Each patient must sign a Notice of Privacy Practices acknowledgement form.
The patient’s name appears on the file folder label in the following order: first name, middle name, last name.
Color-coded labels are attached to the full cut side tab of the file folder.
The patient’s registration form should be placed in front of the medical record.
Punch holes in forms for the patient’s medical record using a 3-hole punch.
In alphabetic filing, legal names are used to identify the indexing units.
In an alphabetic filing system, the patient’s last name is the first indexing unit.
In an alphabetic filing system, all records are cross-indexed.
If the first and second indexing units are the same, the record of a patient with no middle name or initial will come before the record of a patient with a middle name.
Business names are indexed in the order of the words in the name including articles such as a, an, and the.
Prefixes with the last name (such as de, van, or Mc) are indexing units after the patient’s middle name.
If a patient uses an abbreviated first name or nickname as a first name, it should be used as the first indexing unit.
Hyphenated names are indexed as one unit whether first names or last names.
Titles or seniority terms like Jr. or Dr. are considered the third indexing unit.
To file records alphabetically, first sort the records by last name, and then sort records of the same last name by first name.
In order to create a numeric filing system for medical records, each patient must be assigned a number.
It is easier to identify the correct patient record using a numeric filing system when several patients have the same last name.
Terminal digit filing usually uses a four-digit number.
In terminal digit filing, if numbers are in groups of two digits, the final group of numbers is the first filing unit.
If terminal digit filing is used, the numbers of the newest or most active patient are all in the same section of the file shelves.
In the consecutive numeric filing system, numbers are arranged from lowest to highest
If the office uses index cards in an outguide when records are in use, remove the outguide from the shelf and the index card from the outguide when the record is replaced in the file.
All paper reports that come into the medical office should be reviewed by the physician and initialed before they are filed into a patient’s record.
After reading a paper report, the physician may write a note for the medical assistant to follow up before filing the report.
Reports are filed in chronological order in the correct section of the chart after previous reports of the same type
Paper medical records often have prongs that allow parts of the record to be easily removed to facilitate filing reports.
To avoid misplacing files, always use outguides to indicate who has removed a record.
If a record is missing, it isn’t important to look for it, because it will probably turn up eventually.
Reports with tears should be mended before filing to help keep them in good condition.
Remove paper clips from pages and staple if necessary before filing.
It is more efficient to file each report separately than to sort all reports and then file them into the medical record.
Place an outguide into the file to mark a record’s place when you remove a record to add a report.
Which of the following types of medical records may be reviewed to record statistical information?
Paper medical records
Electronic medical records
Both paper medical records and electronic medical records
Neither paper medical records nor electronic medical records
Which of the following are true about both paper medical records and electronic medical records?
They provide for continuity of care.
They provide an ongoing record of the patient’s state of health.
They are legal documents if there is a question about care given.
They usually include information form more than one source.
All of the above.
What usually happens to the paper medical record after a medical office transitions to an electronic health record system?
It is scanned into the electronic medical record but kept available
It is scanned into the electronic medical record and then shredded.
Baseline data and recent information is scanned into the electronic record, and the paper record is photographed and stored digitally.
Baseline data and recent information is scanned into the electronic record, and the paper record is kept available for two to three years
What is used to hold medical records if they are filed in an ordinary file cabinet?
Manila folders with one or more tabs on the side that opens
Manila folders with full-cut side tab
Expanding file folders that open from the top
Legal size file folders without tabs or metal fasteners
What is true about labels used on paper medical records?
Each letter of the alphabet is assigned a different colored label
They are only used for an alphabetic filing system
Pressure-sensitive self-adhesive labels are usually used
A new label is applied each time the patient visits the office
What is used to hold the medical records if the medical office uses a paper medical record?
Vertical drawer file cabinets
Open-shelf filing units arranged horizontally
Shelf filing units with pull-down fronts
Lateral drawer file cabinets
All of the above
What is always necessary if a paper medical record system is used?
A means to back up data every day
A means to lock the medical record storage cabinets or storage room
A means to maintain high humidity in the medical record storage area
Color-coded labels or file folders to facilitate identification of records
When is it recommended that file folders used to hold paper medical records be broken down into two folders?
When the width of the folder reaches 1/4 inch
when the width of the folder reaches 3/4 inch
when the width of the folder reaches 1 1/2 inch
when the width of the folder reaches 2 inches
What is an outguide?
A stiff piece of paper or plastic that is placed in a file when a medical record is removed
A metal device that facilitates removing a medical record from the filing cabinet or shelf
A metal divider that is placed on file shelves at specified intervals to support the records
An index card that is filled out to identify who has taken a medical record from the file
Which of the following is an indirect method of filing?
Chronologic
Alphabetic
What is an advantage of using color-coded labels or folders?
It preserves patient confidentiality.
It simplifies removal of inactive records.
It reduces the risk of misfiling
It simplifies the process of creating the record
If the office is using a color-coded system, who needs to know the meaning of the colors in use?
All office staff
Both office staff and patients
Only the medical assistants
Office staff and staff of the insurance companies billed by the office
In a paper medical record system, how are laboratory reports often filed if they are smaller than 9×12 inches?
Using chart dividers
From the top as separate short pages
Using mounting sheets, with the oldest report in front on top
Using mounting sheets, with the oldest report at the back on the bottom
What is an indexing unit in an alphabetic filing system for medical records?
The patient’s full name
Each color-coded label placed on the medical record
Each part of a patient’s name
Each letter of a patient’s name
What is the first indexing unit in alphabetic filing?
First name
Last name
Middle initial
Professional title
What is the second indexing unit in alphabetic filing?
Second letter of the last name
If two patients have exactly the same name, what information is used to put their medical records in order?
Birth date
Chronologic age
Birthplace
Street address
Which filing system used for paper medical records protects patient identity most successfully?
Cross-indexed
Which of the following would be filed first?
Jones, Jane
Jones, Kristine
Jones, L. W.
Using the alphabetic system of filing, what would “The Harris Office Supply Company” be filed under?
Which of the following names would be filed first?
David de Long
Winston De La Mare
Jacob De Laray
Martha Delmarven
Which of the following names would be filed last?
Bower, E. Lawrence
Bower, Edgar
Bower, Edgar Lawrence
Bower, E. L.
St. James, Anne Marie
St. Charles, Josephine
St. Joseph, Joseph
St. Elmo, Elmer
If Mary Jane Mitchell marries John L. Walker, which of the following names might Mary Jane choose to use as her married name?
Mary Jane Walker
Mary Jane Mitchell
Mary Jane Walker-Mitchell
Mary Walker Mitchell
Which of the following is NOT an advantage of using a numeric filing system?
It is easier to preserve patient confidentiality.
It is easier to identify patients when several patients have the same name.
Fewer label colors are required to mark the medical records.
A separate system must be maintained to link the patient’s name with the numbering system
If the terminal digit filing system is used, what is the first filing unit for the number 01-68-72-59?
01
59
68
72
If the terminal digit filing system is used, which of the following medical record numbers comes first in the files?
02-19-81-86
19-44-01-10
32-94-47-03
72-81-19-02
If a chronological numeric filing system is used, which of the following medical records comes last in the files?
0219
1944
3294
7281
Which of the following makes it easier to find a paper medical record that has been removed from the files?
Handing the paper medical record from one person to another until everyone who needs to use it is finished
Filling out a card to place in the outguide for every record that was removed
Placing medical records in stacks that have no more than five records each
Keeping the medical records in good repair by securing loose pages and mending tears
Where should the medical assistant’s paper tickler files be stored?
Near the inactive medical record files
In a locked cabinet
In a desk or file cabinet near where the medical assistant usually sits
In the patient waiting room
If the subject method of filing is used for folders, which of the following would be filed first?
Bank accounts
Cleaning services
Pharmaceutical companies
Medical supply companies
What must occur before a piece of correspondence can be filed in a patient’s paper medical record?
It must be indexed.
It must be coded.
It must be annotated
It must be initialed by the physician.
In what order are documents filed into a section of the source-oriented medical record?
The order in which they are received in the office
With the oldest date first
In reverse chronologic order (most recent first)
In random order
What determines the classification of “inactive” for a medical record?
State law
Federal regulations
Office policy
OSHA recommendations
How long should the medical records of minors be kept?
Indefinitely—no medical record should ever be destroyed
Until the patient becomes 18 years of age.
Until the patient becomes 21 years of age.
Until the patient reaches the age of majority plus the number of years for the statute of limitations in that particular state
When can a physician destroy a patient’s file?
If the patient was treated only once.
When the record has been inactive at least seven years after the statute of limitations has expired
If the patient transfers to another physician.
Legally, medical records can never be destroyed.
Which of the following is the least common method for backing up the electronic medical record?
DVD optical disks
External hard drive
External tape drive
Network storage
Why are inactive records removed from the active file area in most offices?
To avoid confusion between active and inactive files
To create more space for the records of new patients
Because they are no longer necessary for billing
To protect them from constant wear and handling
What is a guideline for the storage of backup copies of electronic medical records?
If possible, they should be stored off site in a secure location.
They should be stored in a locked file cabinet in the office.
Their storage area should always be protected from light.
They should be encrypted so that only the system administrator can load them into the computer.
Which of the following should be avoided in a storage area for inactive medical records?
Relative humidity between 48% and 52%
Keeping lights off unless someone is actually present in the storage area
Dust and exposure to insects
Secondary aisles that are only 3 feet wide
A numeric filing system is only used for problem-oriented medical records (POMR).
It is common for paper medical records to be filed based on the date of the patient’s last visit.
If paper medical records are stored in file cabinets, it is more common to use lateral drawer file cabinets than vertical drawer file cabinets.
File folders used for paper medical records are similar to loose-leaf notebooks.
A sorter is a device that facilitates placing documents in alphabetic or numeric order.
If a patient has a hyphenated last name, it may be helpful to cross-index the medical record in an alphabetic filing system.
In an alphabetic filing system, the name Helen Walker Durand would be filed after Helen Walker-Durand.
A large practice is more likely to use a terminal digit numeric filing system than a chronologic numeric filing system.
Most offices that use paper medical records place a sticker identifying the year of the patient’s last visit on the outside of the chart to facilitate identifying active records.
The medical record of a Medicare patient must be retained for at least ten years after the last contact with the patient.
