Chapter 13 - Managing Medical Records

Question 1

Who makes the final decision on how long to keep inacive or closed patient files in the office before sending them to storage?

Answer 1

The licensed practitioner

Question 2

All information in the patient’s chart should be what?

Answer 2

Initialed, dated, and filed

Question 3

Medical records must be kept for how many years from the date of the last visit?

Answer 3

7 years

Question 4

Steps in filing:
System for storing documents, whether alphabetically, numerically, or alphanumerically.

Answer 4

Indexing

Question 5

Steps in filing:
The physician has authorized the document to be put into the patients folder.

Answer 5

Inspecting

Question 6

Steps in filing:
Files are put in groups in which they will be stored, such as numerically or alphabetically.

Answer 6

Sorting

Question 7

Steps in filing:
Documents are filed in the correct order and in the correct file, files are in good condition, and a notation is made if there is more than one folder for a patient.

Answer 7

Storing

Question 8

Steps in filing:
An identifying mark or phrase is placed on a document to ensure that it is placed in the correct file.

Answer 8

Coding

Question 9

In middle digit numeric filing, what is the primary index?

Answer 9

The middle group of numbers

Question 10

What are closed files?

Answer 10

Files of patients who are no longer treated at the practice

Question 11

What is the first step in the filing process?

Answer 11

Inspecting

Question 12

How long should you look for a file before concluding that it is lost?

Answer 12

24-48 hours

Question 13

What regulation states there must be a “reasonable safeguard” to protect PHI from disclosure?

Answer 13

HIPAA

Question 14

What is one way to reduce the number of misplaced records?

Answer 14

Appropriately train staff on filing guidelines

Question 15

What is the correct order for the steps of filing?

Answer 15

Inspecting & releasing, indexing, coding, sorting, storing

Question 16

Separate patient files that contain insurance payment information are known as what?

Answer 16

Supplemental files

Question 17

What is not considered a good option for filing active paper medical records?

Answer 17

Plastic tubs or boxes

Question 18

What is color coding used for?

Answer 18

Distinguishing files within a filing system

Question 19

What is the most basic filing supply?

Answer 19

Folder

Question 20

What is the most common and simplest type of filing system for maining patient files?

Answer 20

Alphabetic system

Question 21

Active, Inactive, or Closed file?
Patient is deceased

Answer 21

Closed

Question 22

Active, Inactive, or Closed file?
Patient who has not been seen by the PCP in four years?

Answer 22

Inactive file

Question 23

Active, Inactive, or Closed file?
Patient seen last week with a follow-up appointment in one week?

Answer 23

Active file

Question 24

Tickler files should be arranged according to what?

Answer 24

The date of the appointment

Question 25

Filing system in which files are grouped according to colors assign to specific groups

Answer 25

Color coding

Question 26

In which filing system are files arranged by patients last name first, followed by the first name, and the middle initial

Answer 26

Alphabetic

Question 27

In which filing system are files arranged according to numbers assigned to patient files?

Answer 27

Numeric

Question 28

What is a date order reminder file?

Answer 28

Tickler file

Question 29

What is the purpose of labeling files on the outside of the drawer?

Answer 29

To identify what is in the drawer without having to open it

Question 30

What should you do if you are in charge of the tickler file but you are going to be out for 2 days on jury duty?

Answer 30

Assign someone as a backup person to check the files while out

Question 31

If a patient has not been seen at the office for the past five years, he is an inactive patient, what should happen to the file?

Answer 31

Transferred to storage

Question 32

Inactive files are . . .

Answer 32

Used infrequently

Question 33

What is the second step in the filing process?

Answer 33

Indexing

Question 34

A chronological file used as a reminder is called what?

Answer 34

Tickler file

Question 35

According to the IRS, financial records should be retained for how long?

Answer 35

10 years

Question 36

Which filing system is most appropriate for a practice with more than 15,000 active patient records?

Answer 36

Numeric

Question 37

Which filing system is used due to its speed and simplicity?

Answer 37

Alphabetic

Question 38

What should replace a patients medical record when the record is removed from the filing system?

Answer 38

Out guide

Question 39

What filing system best provides confidentiality of patient information?

Answer 39

Numberic

Question 40

Arranging items to be in a sequence before going into the file cabinet is called what?

Answer 40

Sorting

Question 41

What is a compactible file?

Answer 41

A file kept on rolling shelves that slide along permanent tracks. Stored close together/stacked.

Question 42

Lateral File

Answer 42

A horizontal filing cabinet

Question 43

What is a records management system?

Answer 43

How patients records are created, filed, and maintained

Question 44

What is a retention schedule?

Answer 44

Schedule detailing how long records should be stored

Question 45

What is sequential order?

Answer 45

One after another in a predictable pattern or sequence

Question 46

What is a unit?

Answer 46

A part of an individuals name or title, described in index ruling

Question 47

What is a verticle file?

Answer 47

File cabinet that is taller than wide

Question 48

Tapered, regular, or rounded extension at the top or side of a folder

Answer 48

tabs

Question 49

Indentifies the contents of individual folders

Answer 49

labels

Question 50

Regular file folders but have hooks on the side that allows the folder to hang from the metal bars inside the drawer

Answer 50

Hanging file folders

Question 51

Stronger than a file folder but require more space

Answer 51

binders

Question 52

Heavy, cardboard or plastic inserts the separate the contents in a drawer so individual files can be found easily

Answer 52

file guides

Question 53

Large, accordian style folders

Answer 53

file sorters

Question 54

What is the first step in locating a misplaced file?

Answer 54

Determine the last time you or anyone else knew the file location