For how many years should a provider store medical records (select the least number of years that maintains compliance with state and federal
... [Show More] regulations)?
Afford 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
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.
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. takes a full set of vital signs
C. reposition the finger probe
D. notifies the physician
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.
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
C. living will
D. assignment of benefits
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).
A.reservoir host
B. portal of exit
C. means of transmission
D. portal of entry
E. susceptible host
Rationale: Infectious diseases are spread through a series of steps known as the "chain of infection". For an infection to occur and spread, each of the six links of the chain must take place. Removing any link in the chain will stop the cycle. Therefore, identifying and instituting appropriate actions at different steps in the cycle will halt the spread of the infection. The chain begins with the infectious agent (bacteria, virus,etc.) and spreads to a reservoir (place to live, like an animal, insect, water, etc.). The portal of exit is a way for the microorganism to leave the reservoir (in a cough, feces, etc.) to transmit the disease. The mode of infection refers to how infectious diseases are spread: by contact,
The medical assistant schedules a follow-up appointment for a patient following surgical removal of their uterus. The medical term for this procedure is
A. amniocentesis.
B. oophorectomy.
C. uteroscopy.
D. hysterectomy
Rationale: The definition of a Hysterectomy is Hyster- = uterus, ectomy = surgical removal of. An Oophorectomy is the surgical removal of an ovary or ovaries, an Ureteroscopy is an examination of the upper urinary tract, and Amniocentesis is a test used to determine whether an unborn baby has any genetic abnormalities. [Show Less]