Ch1 Medical Transcription Quiz

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.

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.

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.

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.

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.

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.

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.

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.

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.

Make sure you spell correctly to get the answer right