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For how many years should a provider store medical records (select the least
number of years that maintains compliance with state and federal regulations)?
A. 15 years
B. 10 years
C. 5 years
D. 20 years - ✔✔Correct response:
10 years
Rationale: Federal and state regulations require a minimum storage time frame
for medical records. State regulations may require a longer or shorter time
frame, depending on the state. Every medical provider should routinely check
state and federal requirements to remain compliant. As of the date this
question was submitted (2015), a 7 to 10 year time frame would meet all
federal and state medical record storage requirements.
Flow charts, progress notes, and narrative notation are all examples of
A. medical record charting styles.
B. patient documentation in a SOAP format.
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,C. recording patient information in a medical record.
D. patient chart filing systems. - ✔✔Correct response:
recording patient information in a medical record.
Rationale: Patient information can be recorded in the medical record in a
variety of ways. Progress notes, flow charts and narrative notation are all
effective ways to document a patient's medical information. The SOAP format is
the documentation system chosen by many physicians. S=Subjective patient
interview information, O=Objective information such as vitals, lab values, etc.,
A=Assessment of the "S" and "O" data, P=Plan for treatment or follow-up.
Medical records of various styles are generally kept in charts, which are filed
according to a filing system.
When measuring oxygen saturation on a child breathing room air, with normal
color, and no signs of respiratory distress, the medical assistant obtains a
reading of 79%. Which of the following actions should the medical assistant take
next?
A. supplement the child with oxygen per protocol
B. take a full set of vital signs
C. reposition the finger probe
D. notify the physician - ✔✔Correct response:
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,reposition the finger probe
Rationale: Oxygen saturation (O2 Sat or Pulse Ox) on a child with a structurally
normal heart should be >92% . Patient movement, poor probe attachment, or
nail polish can distort the sensor reading during monitoring. Always observe the
child's condition first, and machine reading 2nd when troubleshooting. O2
saturation should be obtained and documented as part of a full set of vital signs
for patients being evaluated for respiratory conditions.
Which of the following is the best way to correct AC interference on an ECG?
A. Ask the patient not to move while performing the test.
B. Move the patient to a quiet room.
C. Check that the patient does not have a cell phone close by.
D. Offer the patient a blanket if she is cold. - ✔✔Correct response:
Check that the patient does not have a cell phone close by.
Rationale: AC is alternating current interference and it can be caused by a
nearby electrical device (such as a cell phone). Patient movement (either
voluntary or shivering from the cold) can cause other artifact on an ECG, but not
the same as AC interference. Moving the patient to a quiet room would not
alleviate AC interference.
Which of the following documents is also called an advanced directive?
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, A. subpoena
B. informed consent
C. living will
D. assignment of benefits - ✔✔Correct response:
living will
Rationale: A living will is a formal document, written in advance, that gives
health care professionals instructions about the patient's medical wishes
regarding end of life care, and is the same as an advanced directive. Assignment
of benefits refers to the patient's wishes on who and where they want their
money sent to, a subpoena is an order given to someone who is supposed to go
to court, and informed consent refers to a document that a patient fills out
which gives permission to the healthcare providers to perform certain tasks or
procedures.
Beginning with the infectious agent, place the elements in the correct order of
the chain of infection. (Click and drag the options in the left column to their
correct order in the right column).
reservoir host
portal of exit
means of transmission
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