Medical Records Management Flashcards
6 cards from real CMAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Records Management flashcards as text
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?
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'.
Which of the following is the proper procedure for correcting an error in a patient's paper medical record?
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.
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?
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.
What is the primary distinction between an Electronic Medical Record (EMR) and an Electronic Health Record (EHR)?
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.
A patient's complaint of a persistent cough and sore throat would be documented in which section of a SOAP note?
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.
For a HIPAA authorization form to be valid for the release of medical information, which of the following elements is required?
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.