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15 questions
Two standard names of two types of medical records
Medical History Form
Patient Information Sheet
Statistical Data Sheet
Administrative Medical Form
Medical record management requires
accuracy
Proper filing and storage
confidentiality
all of the answers are true
Patient information in their medical record should include
a record of divoreces
the date of birth
the date of marriage
the date of the spouses birth
Information usually found on a Statistical Data Sheet
Name, DOB, address, insurance info, occupation
Name, reason for visit, date, spouses occupation, parents names
Name, date of birth, date, health history, complaint
Name, Insurance info, family history, personal history, signature
The accepted method of correcting medical record errors is
erase and write the correction
draw a line through the error and write the correction underneath
draw a line through the error and write the correction above with the date and initials of the person making the correction
erase and write the correction, adding the date and initials of the person making the correction
When filling out medical forms what writing utensil should be used?
red pen
blue pen
permanent marker
black pen
An incomplete medical record may
not be a problem,as the remainder of the entry could be discussed during a court hearing
allow only part of a bill to be paid
make it impossible for the healthcare provider to defend allegations in court
not be able to be subpoenaed to court
To protect patient confidentiality, medical records can be released
to an attorney
to the patient's family members
to a judge
only with the patient's written consent
Ownership of the medical record usually remains with the
physician
court
patient
all of the avove
Computerized medical records
pose problems of confidentiality
should be accessed on a a need-to-know basis
make record maintenance and retrieval more efficient
all of the above
Physicians who wish to disclose confidential medical record information should
first discuss it with the patient's family
discuss it with the patient first
discuss the risks involved with his or her lawyer
first discuss the problem with the patient's contact person
Immunization records should be kept
for 10 years
for 5 years
permanently
until the age of maturity
What is the purpose of medical records
to provide a written account of the health care for a patient
to provide a documentation of medical services for insurance purposes
to provide conformation of a patients appointments
What rights do patients have regarding their medical records?
None
Rights to have records destroyed
To view and make copies
Why should you know your own health history and your family's health history?
to know if you have all your immunizations
To have a better diet.
Awareness, Prevention, and Maintenance
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