Chapter 14 Medical Records Managment

Medical records are indeed important for various reasons. They contain crucial information about a patient's medical history, including past diagnoses, treatments, and medications, which is essential for providing appropriate medical care. Additionally, medical records serve as legal protection for healthcare professionals, as they document the care provided and can be used as evidence in case of any legal disputes. Moreover, medical records are valuable for research purposes, as they can be used to analyze trends, identify patterns, and contribute to medical advancements. Therefore, the statement "medical records are important for many reasons" is true.

EMR stands for electronic medical records. This refers to a digital version of a patient's medical history, including diagnoses, treatments, medications, and other relevant information. Electronic medical records are used by healthcare professionals to store and access patient data, allowing for efficient and accurate documentation, communication, and decision-making. This technology has revolutionized the healthcare industry by improving patient care, reducing medical errors, and facilitating research and analysis.

The best method to use for making a correction in a paper medical record is to draw a single line through the error, make the correction, write "CORR" or "CORRECTION" above the area corrected, and add your initials and date. This method ensures that the original error is still visible but clearly marked as corrected, and provides a clear record of who made the correction and when it was made. Using "white out" or scribbling over the error with a magic marker can make the record messy and difficult to read, while putting "x's" through the error does not clearly indicate that a correction has been made.

This statement suggests that in a court of law, if there is no documented evidence or record of information regarding the appointment, care, and treatment of a patient, it is considered as if it never happened. This implies that without proper documentation, it becomes difficult to prove the occurrence of any medical procedures or actions in a legal setting. Therefore, the answer "True" indicates that the statement accurately reflects the standard in court regarding the absence of documented information.

The identifiable patient information that should not appear on the outside of the chart includes the patient's address, social security number, and birthday. This information is considered sensitive and should be kept confidential to protect the patient's privacy and prevent potential misuse or identity theft. Including all of the above information on the outside of the chart would pose a risk to the patient's privacy and security.

The statement is incorrect. It is not acceptable to release medical information to family members solely based on showing proper picture identification. Medical information is protected by privacy laws and can only be released with the patient's consent or in certain specific situations outlined by law. Proper identification alone does not grant access to someone's medical records.

The correct answer is "all of the above" because the statement mentions three different characteristics that filing equipment should have. It should have a locking capability to ensure the security and confidentiality of the stored documents. It should be available in vertical or lateral styles, providing options for different storage needs. Lastly, it should be stored in an area accessible only to authorized personnel, further enhancing the security measures. Therefore, all three statements are true and make up the correct answer.

The skill of being good at math is not important when filing because filing primarily involves organizing and categorizing documents based on their content or alphabetical order. Math skills are not directly relevant to this task.

When any information needs to be released from a medical record, it is necessary to obtain the patient's notification and approval. This ensures that the patient is aware of the information being released and gives their consent for it to be shared with the medical insurance or any other party. Without the patient's notification and approval, it would be a violation of their privacy to release their medical information.

The statement that all medical filing systems use the alphabetic filing system is false. While many medical filing systems do use the alphabetic filing system, there are also other methods used such as numeric filing, which organizes files based on numbers, and subject filing, which organizes files based on specific topics or categories. Therefore, it is not accurate to say that all medical filing systems solely rely on the alphabetic filing system.

The most common method of filing in today's medical office is alphabetically. This means that documents and records are organized and stored in alphabetical order based on the patient's last name. This method allows for easy retrieval and access to patient information, as it follows a logical and familiar system. It also helps in maintaining consistency and efficiency in the medical office's filing system.

Numeric filing is the most important reason for preserving patient confidentiality because it allows for the identification and organization of patient records using a unique numerical system. This system ensures that patient information is kept private and secure, as only authorized personnel who have access to the numerical code can retrieve the records. Unlike alphabetical filing, where patient names are easily identifiable, numeric filing provides an added layer of confidentiality by using numbers instead of names.

The tickler system is a method used to remind patients to return for another examination in six months. It helps healthcare providers keep track of upcoming appointments and ensures that patients receive timely reminders. This system is commonly used in medical settings to improve patient compliance and follow-up care.

According to state statutes, medical records are considered the property of the one who created them. This means that the healthcare provider or facility that generated the medical records has ownership over them. This is important because it allows the healthcare provider to control access to the records and ensure their confidentiality. It also means that patients may need to request access to their own medical records and may have limited control over them.