Chapter 1 Medical Transcription

If a patient's medical records are presented in court as evidence in a professional liability case and they have been sloppily corrected, it suggests that the records might have been intentionally altered. This implies that someone may have intentionally changed the records to hide information or manipulate the evidence. If the prosecuting attorney can prove this intentional alteration, it strengthens their case against the defendant, increasing the chances of winning the case. Therefore, the statement "True" is the correct answer.

The statement is true because discharge summaries records are required to be completed within a certain time frame following discharge. In this case, the time frame mentioned is 30 days, meaning that the discharge summaries must be completed within this period. This ensures that the necessary information about the patient's condition, treatment, and follow-up care is documented in a timely manner, allowing for effective communication and continuity of care between healthcare providers.

The main purpose of medical records is to assist in the diagnosis and treatment of a patient by communicating with the attending physician and other medical personnel working with the patient. It also aids and advances the science of medicine and ensures compliance with laws and accreditation requirements for medical report completeness, signatures, abbreviations, deadlines, and dates of documents.

The correct answer is Federal Law because it states that physician's signatures in a medical record are required for hospital compliance with Medicare conditions of participation and to qualify for reimbursement under the prospective payment system. This indicates that the requirement is mandated by a federal law.

Operative reports should be dictated or written in the medical record immediately before surgery. This statement is false. Operative reports should actually be dictated or written immediately after surgery, not before. This ensures that all the details of the surgery are accurately documented while they are still fresh in the surgeon's mind. Writing the report before surgery could lead to inaccuracies or missing information.

Medical records are the property of the corporation, physician, or institution that provided the care. This means that any of these entities have ownership rights over the medical records. Therefore, all of the options listed (corporation, physician, institution) are correct answers.

The statement is false because when a necropsy is performed, provisional anatomic diagnoses should be recorded in the medical record within 5 days, and the complete protocol should be made part of the record within 120 days.

Physical assessment is an important part of the admission process for inpatient services. It helps healthcare professionals gather information about the patient's overall health, identify any existing conditions or concerns, and establish a baseline for further treatment. Completing the physical assessment within the first 24 hours of admission ensures that any immediate medical needs or concerns can be addressed promptly, allowing for appropriate and timely interventions to be implemented.

Medical records can be classified into two categories: non privileged and privileged. Non privileged information refers to data that can be accessed by anyone involved in the patient's care, such as medical history, test results, and treatment plans. On the other hand, privileged information is confidential and can only be accessed by authorized individuals, such as mental health records or substance abuse treatment records. This classification helps to ensure the privacy and confidentiality of sensitive medical information.

The correct answer is: Date when care was provided, Date when the document was dictated, Date when the document was transcribed.

In order to provide a comprehensive report, it is important to include three specific dates. The first date refers to when the care or service was provided, which helps provide context and relevance to the report. The second date signifies when the document was dictated, indicating when the information was recorded or documented. Lastly, the third date represents when the document was transcribed, indicating when the information was converted into written form. Including these three dates ensures accuracy and transparency in the report.