Medical records are not allowed to be used for clinical data relating to education and research.

True

False

False

This is an acceptable use of medical records. 

To be reliable as legal documents medical records must be:

• Relevant, accurate, legible, timely, informative, and complete.
• Recognized, accurate, legible, thorough, illustrative, and comprehensive.
• Recognized, accurate, legible, thorough, informative, and comprehensive.
• Relevant, acceptable, legible, timely, informative, and comprehensive.

Relevant, accurate, legible, timely, informative, and complete.

**This was taken directly from the text on P. 129

A ______ _____________ may be used if health care information is needed more quickly than can be accomplished by mail, phone, or computer.

Protect client condentiality when using computers by creating passwords that are not easily guessed and changed at least every ____ _________.

An error in a medical record is corrected by

• crossing out the error so you can't see it anymore, writing "correction" or "error", writing in the correct information, signing your initials and writing the date.
• erasing the error and entering the correct information.
• drawing a line through the error, writing "correction" or "error", making the correction, signing your initials and dating.
• Use a red pen, obliterate the error, make the correction and then sign and date it.

drawing a line through the error, writing "correction" or "error", making the correction, signing your initials and dating.

An authorization to release information to a third party should be in writing only

True

False

Under no circumstances can medical records be released to a third party unless written authorization from the patient is received. 

True

False

False

There are many examples of situations where a release of records can occur without the patient's authorization. Examples include reportable diseases (e.g. chlamydia),and court orders.

A patient does not have the right to find out who has had access to his or her records.

True

False

False

Under HIPAA, privacy notices must include information indicating that a patient has the right to receive an accounting of PHI disclosures related to their records.

Email communication between a physician and patient has which of the following advantages

• creates a written record, allows for education links, and avoids "phone" tag between physician and patient.
• creates a written record, eliminates need for patient consent, and allows for use of communication in a malpractice suit.
• creates a written record, is always private and condential, and allows for the use of education links.
• creates a written record, allows for communication to be used in a malpractice suit, and eliminates misreading or misunderstanding by the patient.

creates a written record, allows for education links, and avoids "phone" tag between physician and patient.

 In all cases, medical records should be kept for a minimum of 5 years since the patient was first seen.

True

False

False

Guidelines for retaining records vary depending upon state statutes, the type of records involved, and hospital vs. clinic records.

With increased health awareness and HIPAA considerations, clients are less concerned about what goes into their

medical record.

True

False

POMR is the abbreviation for a style of charting in a medical record referred to as Patient Oriented Medical Record.

True

False

False

POMR stands for Problem-oriented Medical Record

HIPAA has specic regulations about protected health information (PHI) as it relates to electronic medical records.

True

False

Who owns the client's medical record?

• The client
• The client's physician
• The client's family
• Client's medical insurance company

The client's physician

It is recommended that physicians keep clients' medical records at least until the:

• Good Samaritan Law expires.
• Statute of limitations has run out.
• Client changes physicians.
• Court subpoenas the record.

Statute of limitations has run out.

SOAPER methods of charting imply the following:

• Subjective, Objective, Assessment, Purpose, Education, and Response
• Signicant, Obvious, Assessment, Plan, Education, and Response
• Subjective, Objective, Assessment, Plan, Education, and Response
• Subjective, Objective, Assessment, Plan, Evaluation, and Response

Subjective, Objective, Assessment, Plan, Education, and Response

E-mail with clients:

• Is a very safe and condential means of communication.
• Is not admissible in a professional liability case.
• Cannot be recovered after it is deleted, thus protecting condentiality.
• Should not be used for correspondence which requires an urgent reply.
• all of the above

Should not be used for correspondence which requires an urgent reply.

The best way to correct an error is to completely mark out the underlying mistake using a marker so the erroneous

words cannot be seen.

True

False

False

You should never obliterate something written in the chart.  Instead, draw a line through the error and then write in the correction. 

Which of the following is NOT a purpose of the medical record?

• Serves as a legal basis for litigation
• Protects only the legal interest of the provider
• Documents total health care from birth
• Provides clinical data for education and research

 Protects only the legal interest of the provider

Regardless of the storage medium in which a medical record is saved, inactive charts should be protected with the same safety measures as active charts.

True

False