Question

QUESTION 1: The best color ink to use for medical records is blue or black.

True

False

QUESTION 2: What does the mnemonic FLOAT stand for?

	a.	Factual, Legal, Objective, Accurate, and Timely
	b.	Factual, Legible, Objective, Accurate, and Timely
	c.	Fidelity, Legible, Objective, Accurate, and Timely
	d.	Factual, Legible, Observed, Accurate, and Timely

QUESTION 3: Match each part of the FLOAT method to its correct explanation

FACTUAL LEGIBLE OBJECTIVE ACCURATE TIMELY

a. This suggests impartiality and fairness. Personal opinions have no place in the medical record. b. This is of the essence in medical accountability. When you are with a patient, you should be making notes immediately to ensure the most accurate information. c. A medical record, if brought into a legal case, will be reviewed and possibly presented as evidence. The phrase “not recorded . . . did not happen” will be enforced. d. This is can be the difference between a patient experiencing improved health and one experiencing a life-threatening situation. You should always double-check to assure that you have the correct medical record before beginning to document—a simple, yet costly mistake. e. This is important because people can misinterpret information because of poor handwriting. If people cannot read your writing, they cannot assess patient information.

QUESTION 4: The Joint Commission's (TJC) mission is “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value".

True

False

QUESTION 5: The medical record is not considered a legal document.

True

False

QUESTION 6: Autonomy is a person’s ability to make decisions concerning his or her own personal well-being, including health care.

True

False

QUESTION 7: Match each part of the SOAP charting method to its explanation

Subjective Objective Assessment Plan of action

a. Conclusions based on the subjective and objective information b. The patient’s chief complaint c. The healthcare professional’s observations and findings through examination and conversation d. The treatment that is advised based on the conclusions

QUESTION 8: All of the following are ethical issues concerning the electronic medical record (EMR) except:

	a.	Retention
	b.	Trust
	c.	Fidelity
	d.	Autonomy

QUESTION 9: What does Stage 1 of the Meaningful Use Regulations (MUR) address?

	a.	health outcomes
	b.	exchange of information
	c.	advancing clinical processes and ensuring that the meaningful use of EHRs supported the aims and priorities of National Quality Strategy
	d.	requirements for data acquisition and providing patients with electronic copies of their health information

QUESTION 10: What information that is to be included in a patient medical record?

	a.	Personal information
	b.	HIPPA Forms
	c.	Telephone conversations between office staff or physicians
	d.	All of the above

Answer 1

ANSWER 1: TRUE

REASON - black / blue ink can be photocopied well as compared to other colored inks

ANSWER 2 B- factual legible objective accurate timely

ANSWER 3  factual - c

Legible -e

Objective - a

Accurate b

Timely - d

ANSWER 4- TRUE

The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

ANSWER 5 FALSE - medical records are considered as a legal document

ANSWER 6 TRUE

AUTONOMY IS THE STATE OF BEING SELF GOVERNING

ANSWER 7 subjective - b

Objective-c

Assessment- a

Plan of action -d

ANSWER 8 A )RETENSION

this is actually one of its benifits

ANSWER 9 D- requirements for data acquisition & providing patients with electronic copiesof their health informations

ANSWER 10 A - PERSONAL INFORMATION