Chapter 1 Medical Transcription

1.

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

A.

True
B.

False

Correct Answer
B. False

Explanation
Operative reports should be dictated or written in the medical record immediately before surgery. This statement is false. Operative reports should actually be dictated or written immediately after surgery, not before. This ensures that all the details of the surgery are accurately documented while they are still fresh in the surgeon's mind. Writing the report before surgery could lead to inaccuracies or missing information.

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2.

Information in medical records falls into which two classifications?

A.

Electronic and written
B.

Non privileged and privileged
C.

Dictated or written.
D.

Diagnostic or therapeutic

Correct Answer
B. Non privileged and privileged

Explanation
Medical records can be classified into two categories: non privileged and privileged. Non privileged information refers to data that can be accessed by anyone involved in the patient's care, such as medical history, test results, and treatment plans. On the other hand, privileged information is confidential and can only be accessed by authorized individuals, such as mental health records or substance abuse treatment records. This classification helps to ensure the privacy and confidentiality of sensitive medical information.

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3.

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

Correct Answer
24
twenty four

Explanation
Physical assessment is an important part of the admission process for inpatient services. It helps healthcare professionals gather information about the patient's overall health, identify any existing conditions or concerns, and establish a baseline for further treatment. Completing the physical assessment within the first 24 hours of admission ensures that any immediate medical needs or concerns can be addressed promptly, allowing for appropriate and timely interventions to be implemented.

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4.

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

A.

True
B.

False

Correct Answer
A. True

Explanation
The statement is true because discharge summaries records are required to be completed within a certain time frame following discharge. In this case, the time frame mentioned is 30 days, meaning that the discharge summaries must be completed within this period. This ensures that the necessary information about the patient's condition, treatment, and follow-up care is documented in a timely manner, allowing for effective communication and continuity of care between healthcare providers.

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5.

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

A.

Doctors
B.

Government
C.

Federal Law
D.

Patients

Correct Answer
C. Federal Law

Explanation
The correct answer is Federal Law because it states that physician's signatures in a medical record are required for hospital compliance with Medicare conditions of participation and to qualify for reimbursement under the prospective payment system. This indicates that the requirement is mandated by a federal law.

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6.

Reports should include three dates: Date when _____ was provided. Date when the _ was dictated. Date when the document was ____. Example: blah, blah, blah (type your answer with your own choices like the example, to fill in the blanks)

Correct Answer
Care, document, Transcribed
Service, report, Transcribed

Explanation
The correct answer is: Date when care was provided, Date when the document was dictated, Date when the document was transcribed.

In order to provide a comprehensive report, it is important to include three specific dates. The first date refers to when the care or service was provided, which helps provide context and relevance to the report. The second date signifies when the document was dictated, indicating when the information was recorded or documented. Lastly, the third date represents when the document was transcribed, indicating when the information was converted into written form. Including these three dates ensures accuracy and transparency in the report.

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4

7.

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.

A.

True
B.

False

Correct Answer
B. False

Explanation
The statement is false because when a necropsy is performed, provisional anatomic diagnoses should be recorded in the medical record within 5 days, and the complete protocol should be made part of the record within 120 days.

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8.

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.

A.

True
B.

False

Correct Answer
A. True

Explanation
If a patient's medical records are presented in court as evidence in a professional liability case and they have been sloppily corrected, it suggests that the records might have been intentionally altered. This implies that someone may have intentionally changed the records to hide information or manipulate the evidence. If the prosecuting attorney can prove this intentional alteration, it strengthens their case against the defendant, increasing the chances of winning the case. Therefore, the statement "True" is the correct answer.

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9.

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

A.

Corporation
B.

Physician
C.

Institution
D.

All of the above
E.

None of the above

Correct Answer
D. All of the above

Explanation
Medical records are the property of the corporation, physician, or institution that provided the care. This means that any of these entities have ownership rights over the medical records. Therefore, all of the options listed (corporation, physician, institution) are correct answers.

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1

0

10.

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?

A.

List of types of transcriptions
B.

Guidelines for Rights to Privacy.
C.

The main purpose of medical records

Correct Answer
C. The main purpose of medical records

Explanation
The main purpose of medical records is to assist in the diagnosis and treatment of a patient by communicating with the attending physician and other medical personnel working with the patient. It also aids and advances the science of medicine and ensures compliance with laws and accreditation requirements for medical report completeness, signatures, abbreviations, deadlines, and dates of documents.

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Chapter 1 Medical Transcription

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

Information in medical records falls into which two classifications?

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

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

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

Reports should include three dates: Date when _________ was provided. Date when the _________ was dictated. Date when the document was ________. Example: blah, blah, blah (type your answer with your own choices like the example, to fill in the blanks)

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.

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.

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

Reports should include three dates: Date when _____ was provided. Date when the _ was dictated. Date when the document was ____. Example: blah, blah, blah (type your answer with your own choices like the example, to fill in the blanks)