Ch1 Medical Transcription Quiz
Closed book, NO notes, No cellphones, and no discussing questions or answers to other students and lastly, absolutely no cheating. Any one caught cheating will get a zero.
Questions and Answers
- 1.
Physical assessment shall be completed within the first _______ hours of admission to inpatient services.
Explanation
Physical assessment should be completed within the first 24 hours of admission to inpatient services. This is a crucial timeframe to assess the patient's physical condition and identify any immediate health concerns or issues that need to be addressed. Completing the assessment within this timeframe allows healthcare providers to develop an appropriate care plan and ensure the patient's safety and well-being during their stay in the hospital.Rate this question:
- 2.
Operative reports should be dicatated or written in the medical record immediately before surgery.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
Operative reports should not be dictated or written in the medical record immediately before surgery. This is because operative reports are meant to document the details of the surgery that has already been performed, including the procedure, findings, and any complications. Dictating or writing the report immediately before surgery would not accurately reflect the actual surgical procedure that took place. Therefore, the correct answer is false.Rate this question:
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- 3.
Information in medical records fall into which two classifications?
- A.
Electronic and written
- B.
Non privileged and privileged
- C.
Dictated or written
- D.
Diagnostic or therapeutic
Correct Answer
B. Non privileged and privilegedExplanation
Medical records can be classified into two categories: non privileged and privileged. Non privileged information refers to medical records that can be accessed by anyone involved in the patient's care, such as doctors, nurses, and other healthcare professionals. On the other hand, privileged information is more sensitive and confidential, and can only be accessed by specific individuals, such as the patient's attorney or a court of law. This classification helps ensure the privacy and security of the patient's medical information.Rate this question:
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- 4.
Discharge summaries records shall be completed within a period of time that will in no event exceed 30 days following discharge.
- A.
True
- B.
False
Correct Answer
A. TrueExplanation
The statement is true because discharge summaries are important medical documents that provide a summary of a patient's hospital stay, including diagnoses, treatments, and follow-up care. Completing these summaries within 30 days following discharge ensures that the information is still fresh and accurate. Timely completion of discharge summaries is crucial for effective communication between healthcare providers and continuity of care for the patient.Rate this question:
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- 5.
____________________ requires physicians signatures in a medical record for hospital compliance with Medicare conditions of participation and to qualify for reimbursement under the prospective payment system.
- A.
Doctors
- B.
Government
- C.
Federal law
- D.
Patients
Correct Answer
C. Federal lawExplanation
The correct answer is Federal law. This is because federal law requires physicians' signatures in a medical record for hospital compliance with Medicare conditions of participation and to qualify for reimbursement under the prospective payment system.Rate this question:
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- 6.
Reports should include three dates: Date when _________ was provided. Date when the _________ was dictated. Date when the document was ________.ANSWER IN THIS FORMAT: answer 1, answer2, answer 3 All 3 must be correct to get this one.
Correct Answer
care, documents, transcribed
care, document, transcribedExplanation
Make sure you spell correctly to get the answer rightRate this question:
- 7.
When a necropsy is performed, provisional anatomic diagnoses should not be recorded in the medical record within 5 days, and the complete protocol should be made part of the record within 120 days.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
The statement suggests that provisional anatomic diagnoses should not be recorded in the medical record within 5 days when a necropsy is performed. However, the complete protocol should be made part of the record within 120 days. The correct answer is false because the statement is incorrect.Rate this question:
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- 8.
If a patient's medical record is presented in court as evidence in a professional liability case and the records have been sloppily corrected, a prosecuting attorney might win a case if it is proved that the records might have been intentionally altered.
- A.
True
- B.
False
Correct Answer
A. TrueExplanation
If a patient's medical records are presented in court as evidence in a professional liability case and they have been sloppily corrected, it means that there have been alterations made to the records. If it can be proven that these alterations were intentionally made, it strengthens the case for the prosecuting attorney. This is because intentionally altering medical records can be seen as an attempt to cover up mistakes or negligence, which can be used as evidence against the defendant in the case. Therefore, the answer "true" is correct.Rate this question:
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- 9.
Medical records are property of the ________________________ that provided the care.
- A.
Corporation
- B.
Physician
- C.
Institution
- D.
All of the above
- E.
None of the above
Correct Answer
D. All of the aboveExplanation
Medical records are property of the corporation, physician, and institution that provided the care. This means that all three entities have ownership rights over the medical records.Rate this question:
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- 10.
1. Assist in the diagnosis and treatment of a patient by communicating with the attending physician and other medical personnel working with the patient. 2. Aid and advance the science of medicine. 3. Comply with laws and serve in support of claim the accreditation manual states requirements for medical report completeness, signatures, abbreviations, deadlines, and dates of documents. These 3 things are?
- A.
List of types of transcriptions
- B.
Guildelines for Rights to Privacy
- C.
The main purpose of medical records
Correct Answer
C. The main purpose of medical recordsExplanation
The correct answer is the main purpose of medical records. The given options mention different aspects related to medical records, such as types of transcriptions and guidelines for rights to privacy. However, the main purpose of medical records is to assist in the diagnosis and treatment of a patient by communicating with medical personnel and to aid and advance the science of medicine. The options provided do not encompass the comprehensive role and importance of medical records in healthcare.Rate this question:
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Current Version
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Mar 22, 2023Quiz Edited by
ProProfs Editorial Team -
Sep 29, 2010Quiz Created by
Msdanabrown
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