Ch1 Medical Transcription Quiz

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| By Msdanabrown
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  • 1/10 Questions

    If a patient's medical record is presented in court as evidence in a professional liability case and the records have been sloppily corrected, a prosecuting attorney might win a case if it is proved that the records might have been intentionally altered.

    • True
    • False
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Ch1 Medical Transcription Quiz - Quiz
About This Quiz

Closed book, NO notes, No cellphones, and no discussing questions or answers to other students and lastly, absolutely no cheating. Any one caught cheating will get a zero.

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  • 2. 

    Discharge summaries records shall be completed within a period of time that will in no event exceed 30 days following discharge.

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The statement is true because discharge summaries are important medical documents that provide a summary of a patient's hospital stay, including diagnoses, treatments, and follow-up care. Completing these summaries within 30 days following discharge ensures that the information is still fresh and accurate. Timely completion of discharge summaries is crucial for effective communication between healthcare providers and continuity of care for the patient.

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  • 3. 

    Physical assessment shall be completed within the first _______ hours of admission to inpatient services.  

    Correct Answer
    24
    twenty-four
    twenty four
    Explanation
    Physical assessment should be completed within the first 24 hours of admission to inpatient services. This is a crucial timeframe to assess the patient's physical condition and identify any immediate health concerns or issues that need to be addressed. Completing the assessment within this timeframe allows healthcare providers to develop an appropriate care plan and ensure the patient's safety and well-being during their stay in the hospital.

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  • 4. 

    1. Assist in the diagnosis and treatment of a patient by communicating with the attending physician and other medical personnel working with the patient. 2. Aid and advance the science of medicine. 3. Comply with laws and serve in support of claim the accreditation manual states requirements for medical report completeness, signatures, abbreviations, deadlines, and dates of documents. These 3 things are? 

    • List of types of transcriptions

    • Guildelines for Rights to Privacy

    • The main purpose of medical records

    Correct Answer
    A. The main purpose of medical records
    Explanation
    The correct answer is the main purpose of medical records. The given options mention different aspects related to medical records, such as types of transcriptions and guidelines for rights to privacy. However, the main purpose of medical records is to assist in the diagnosis and treatment of a patient by communicating with medical personnel and to aid and advance the science of medicine. The options provided do not encompass the comprehensive role and importance of medical records in healthcare.

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  • 5. 

    Operative reports should be dicatated or written in the medical record immediately before surgery.

    • True

    • False

    Correct Answer
    A. False
    Explanation
    Operative reports should not be dictated or written in the medical record immediately before surgery. This is because operative reports are meant to document the details of the surgery that has already been performed, including the procedure, findings, and any complications. Dictating or writing the report immediately before surgery would not accurately reflect the actual surgical procedure that took place. Therefore, the correct answer is false.

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  • 6. 

    ____________________ requires physicians signatures in a medical record for hospital compliance with Medicare conditions of participation and to qualify for reimbursement under the prospective payment system. 

    • Doctors

    • Government

    • Federal law

    • Patients

    Correct Answer
    A. Federal law
    Explanation
    The correct answer is Federal law. This is because federal law requires physicians' signatures in a medical record for hospital compliance with Medicare conditions of participation and to qualify for reimbursement under the prospective payment system.

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  • 7. 

    Medical records are property of the ________________________ that provided the care. 

    • Corporation

    • Physician

    • Institution

    • All of the above

    • None of the above

    Correct Answer
    A. All of the above
    Explanation
    Medical records are property of the corporation, physician, and institution that provided the care. This means that all three entities have ownership rights over the medical records.

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  • 8. 

    When a necropsy is performed, provisional anatomic diagnoses should not be recorded in the medical record within 5 days, and the complete protocol should be made part of the record within 120 days.

    • True

    • False

    Correct Answer
    A. False
    Explanation
    The statement suggests that provisional anatomic diagnoses should not be recorded in the medical record within 5 days when a necropsy is performed. However, the complete protocol should be made part of the record within 120 days. The correct answer is false because the statement is incorrect.

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  • 9. 

    Information in medical records fall into which two classifications? 

    • Electronic and written

    • Non privileged and privileged

    • Dictated or written

    • Diagnostic or therapeutic

    Correct Answer
    A. Non privileged and privileged
    Explanation
    Medical records can be classified into two categories: non privileged and privileged. Non privileged information refers to medical records that can be accessed by anyone involved in the patient's care, such as doctors, nurses, and other healthcare professionals. On the other hand, privileged information is more sensitive and confidential, and can only be accessed by specific individuals, such as the patient's attorney or a court of law. This classification helps ensure the privacy and security of the patient's medical information.

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  • 10. 

    Reports should include three dates: Date when _________ was provided. Date when the _________ was dictated. Date when the document was ________.ANSWER IN THIS FORMAT: answer 1, answer2, answer 3 All 3 must be correct to get this one.

    Correct Answer
    care, documents, transcribed
    care, document, transcribed
    Explanation
    Make sure you spell correctly to get the answer right

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  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Sep 29, 2010
    Quiz Created by
    Msdanabrown
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