ANSWERS
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.
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:
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?
A. subpoena
B. informed consent