Ch1 Medical Transcription Quiz

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1/10 Questions

Physical assessment shall be completed within the first _______ hours of admission to inpatient services.

About This 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.

2.

Operative reports should be dicatated or written in the medical record immediately before surgery.
- True
- False
Correct Answer

A. False

Explanation

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.

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1
3.

Information in medical records fall into which two classifications?
- Electronic and written
- Non privileged and privileged
- Dictated or written
- Diagnostic or therapeutic
Correct Answer

A. Non privileged and privileged

Explanation

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.

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3
4.

Discharge summaries records shall be completed within a period of time that will in no event exceed 30 days following discharge.
- True
- False
Correct Answer

A. True

Explanation

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.

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1
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.
- Doctors
- Government
- Federal law
- Patients
Correct Answer

A. Federal law

Explanation

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.

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2
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, transcribed

Explanation
Make sure you spell correctly to get the answer right

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4
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.
- True
- False
Correct Answer

A. False

Explanation

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.

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3
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.
- True
- False
Correct Answer

A. True

Explanation

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.

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1
9.

Medical records are property of the ________________________ that provided the care.
- Corporation
- Physician
- Institution
- All of the above
- None of the above
Correct Answer

A. All of the above

Explanation

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.

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2
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?
- List of types of transcriptions
- Guildelines for Rights to Privacy
- The main purpose of medical records
Correct Answer

A. The main purpose of medical records

Explanation

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.

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4

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Current Version
Mar 22, 2023

Quiz Edited by
ProProfs Editorial Team
Sep 29, 2010

Quiz Created by
Msdanabrown

Ch1 Medical Transcription Quiz

Physical assessment shall be completed within the first _______ hours of admission to inpatient services.

Quiz Preview

Operative reports should be dicatated or written in the medical record immediately before surgery.

Information in medical records fall into which two classifications?

Discharge summaries records shall be completed within a period of time that will in no event exceed 30 days following discharge.

____________________ 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.

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.

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.

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.

Medical records are property of the ________________________ that provided the care.

Ch1 Medical Transcription Quiz

Physical assessment shall be completed within the first _______ hours of admission to inpatient services.

Quiz Preview

Operative reports should be dicatated or written in the medical record immediately before surgery.

Information in medical records fall into which two classifications?

Discharge summaries records shall be completed within a period of time that will in no event exceed 30 days following discharge.

____________________ 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.

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.

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.

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.

Medical records are property of the ________________________ that provided the care.

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.