CMAA - Certified Medical Administrative Assistant Medical Records Management Questions and Answers 1 — Questions and Answers
Question 1: A CMAA is filing a patient chart with the medical record number 45-82-16 using a terminal digit filing system. In which primary section should the chart be placed?
- In the section for charts beginning with 45
- Chronologically after the last chart filed
- In the primary section labeled 16 (Correct answer)
- In the secondary section labeled 82
Correct answer: In the primary section labeled 16
In a terminal digit filing system, records are filed based on the last two digits (the primary digits) of the medical record number. This method distributes charts more evenly than a straight numeric system. Therefore, the chart with the number 45-82-16 would be filed in the primary section for '-16'.
Question 2: Which of the following is the proper procedure for correcting an error in a patient's paper medical record?
- Completely obscure the error using correction fluid and write the correct information on top.
- Draw a single line through the incorrect entry, write "corr." or "error," add the correct information, and then initial and date the change. (Correct answer)
- Remove the page containing the error and replace it with a new, corrected page.
- Use a black marker to completely cover the incorrect entry and write the correction in the margin.
Correct answer: Draw a single line through the incorrect entry, write "corr." or "error," add the correct information, and then initial and date the change.
The legally accepted method for correcting an error in a paper medical record is to draw a single line through the original entry so that it remains legible. The person making the correction should then add the correct information, initial or sign it, and date it. This ensures a clear and transparent audit trail.
Question 3: A medical office in a state that requires medical records to be kept for 7 years last saw an adult patient covered by Medicare 8 years ago. According to Medicare's Conditions of Participation, their records must be retained for 10 years. What is the appropriate action?
- Shred the record, as the 7-year state requirement has been met.
- Ask the patient if they want a copy before shredding the record.
- Keep the record for a total of 10 years to comply with the more stringent federal regulation. (Correct answer)
- Keep the record indefinitely to be safe.
Correct answer: Keep the record for a total of 10 years to comply with the more stringent federal regulation.
When state and federal regulations for medical record retention differ, the healthcare provider must follow the more stringent (longer) requirement. In this case, the 10-year Medicare requirement supersedes the 7-year state law.
Question 4: What is the primary distinction between an Electronic Medical Record (EMR) and an Electronic Health Record (EHR)?
- An EMR is for clinical notes, while an EHR is strictly for billing and demographics.
- An EHR is designed for interoperability and sharing information across different healthcare organizations, while an EMR is typically a digital record for a single practice. (Correct answer)
- EMR systems are used only in hospitals, and EHR systems are used only in outpatient clinics.
- There is no significant difference; the terms are legally and functionally interchangeable.
Correct answer: An EHR is designed for interoperability and sharing information across different healthcare organizations, while an EMR is typically a digital record for a single practice.
The key difference lies in interoperability. An EMR is a digital version of a patient's chart within one practice. An EHR is a comprehensive record designed to be shared securely among multiple providers, labs, and hospitals, providing a more complete view of a patient's health history.
Question 5: A patient's complaint of a persistent cough and sore throat would be documented in which section of a SOAP note?
- O - Objective
- S - Subjective (Correct answer)
- A - Assessment
- P - Plan
Correct answer: S - Subjective
The "Subjective" section of a SOAP note includes the patient's chief complaint and their own description of their symptoms, feelings, and history related to the visit. It is the information the patient tells the provider.
Question 6: For a HIPAA authorization form to be valid for the release of medical information, which of the following elements is required?
- An expiration date or a specific event that triggers expiration. (Correct answer)
- The patient's preferred contact method.
- The signature of the receiving provider.
- A complete list of the patient's allergies.
Correct answer: An expiration date or a specific event that triggers expiration.
A valid HIPAA authorization must contain several core elements, including a description of the information to be disclosed, the purpose of the disclosure, and a signature. Critically, it must also include an expiration date or an expiration event (e.g., "at the end of the research study") to prevent open-ended access to PHI.
CMAA - Certified Medical Administrative Assistant Medical Records Management Questions and Answers 1
A CMAA is filing a patient chart with the medical record number 45-82-16 using a terminal digit filing system.
In which primary section should the chart be placed?