AES Medical Records questions with verified solutions 2023/2024

AES Medical Records Medical Record - correct answer Provides an account of the health care a patient has received over time Advancement in Health Information Technology has allowed - correct answer More patient records being created, stored, and shared electronically Ownership of medical records - correct answer Medical records are property of the facility that created them; however information within them belong to the patient Laboratory Information - correct answer Includes all lab reports Demographic Data - correct answer Includes personal information: name, social security number, sex, date of birth, address, phone numbers, maritial status, occupation, driver's license number, etc. Insurance Information - correct answer Includes the name and address of the insurance carrier and usually a copy of the patien't insurance card Medical History - correct answer Includes personal and family medical history Correspondence - correct answer Includes letters from specialists or other physicians, request of information letters, and any correspondence from the patient Medication Log - correct answer Includes copies of prescriptiions and documentation of medications that are prescribed by the physician Progress Notes - correct answer Includes a chronological list of visits, treatments, prescriiptions refills, phone calls, and other interactions Diagnositic Information - correct answer Includes x-ray films and other non-laboratory testing Referrals - correct answer Includes copies of forms and letters sent to specialists or other physicians, insurance companies, and patients Past Medical Records - correct answer Includs medical records from prior physicians Importance of Accuracy - correct answer According to law, if no account of an incident appears in a medical record, then the incident did not exist Audits - correct answer An inspection and verification of a facility's records and supporting documents Medical office assistants - correct answer Keep all records neat and orderly so that the facility does not fail the audit Source-oriented medical records - correct answer Separate information according to its source, or type; divided into sections (physicians notes, consultations, laboratory results, etc.) Problem-oriented medical records - correct answer Arrange information by medical problem allowing physicians to easily view trends in the patients health Strict Chronological Arrangement - correct answer Items are arranged by date, regardless of what type of information it is Shingling - correct answer Items that are smaller than a standard-size paper are staggered across a special page with self-adhesive strips Integrated - correct answer Combines all four types of medical records EMR - correct answer Electronic Medical Record CPOE - correct answer Computerized Physician Order Entry; process of electronically entering and sending tratement instructions instead of sending them by paper, fax, or phone