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The document outlines an assignment for a medical records and insurance course, focusing on health records, releasing information, and the importance of Notice of Privacy Practices (NPP). It includes questions and exercises related to health records content, filing methods, and workplace applications regarding electronic health records (EHR) systems. Students are required to utilize Kinn’s The Medical Assistant textbook and study guide to complete the assignment.

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Indi Manning
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8 views6 pages

Homework

The document outlines an assignment for a medical records and insurance course, focusing on health records, releasing information, and the importance of Notice of Privacy Practices (NPP). It includes questions and exercises related to health records content, filing methods, and workplace applications regarding electronic health records (EHR) systems. Students are required to utilize Kinn’s The Medical Assistant textbook and study guide to complete the assignment.

Uploaded by

Indi Manning
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MOA115 Medical Records and Insurance

Week 1 Assignment – Health Records

Chapter 10 Health Records


Part 1 – Releasing Information and NPP
Directions: Answer the following questions. Use your Kinn’s The Medical Assistant e-book as a
resource. Type your answers below the question.
1. Describe when a release form must be signed and indicate what information is included
on the release form.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Describe the Notice of Privacy Practices (NPP) – what is it? Why is it important for
patients to receive the information? (Hint: Use the Index to find the NPP in the
textbook.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Part 2– Study Guide Questions


Directions: Use the Kinn’s The Medical Assistant – Study Guide and Procedure Checklist Manual
for this assignment. You will also need to use the Kinn’s The Medical Assistant textbook as a
resource.

B. Content of the Health Record


1. Which of the following is a reason for having accurate health records?
a. To provide legal protection for those who provided care to the patient
b. To provide critical information for others
c. To provide statistical information that is helpful to researchers
d. To provide the best possible medical care for the patient
e. All of the above

2. Patient’s full name, email address, name of employer, and health insurance information are
all examples of _________________________.
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records

3. Previous illnesses, hospitalizations, and surgeries are considered


_________________________.
4. The _________________________ contains health information about the patient’s parents
and siblings.

5. Lifestyle factors such as tobacco use, employment, and alcohol use are part of the
_________________________.

6. The _________________________ is where information about the nature, location,


frequency, and duration of pain of the patient’s current condition are documented.

Match the description with the type of information. Answers can be used more than once.
a. subjective
b. objective
7. _____ Patient’s address
8. _____ Yellowed eyes
9. _____ Patient’s email address
10. _____ Insurance information
11. _____ Elevated blood pressure
12. _____ Bloated stomach
13. _____ Complaint of headache
14. _____ Weight of 143 pounds
15. _____ Bruises on upper arms
16. _____ Patient’s phone number

17. Which of the following are the medical assistant’s responsibilities when documenting in the
health record?
a. Ensure patient privacy.
b. Use good interviewing techniques to obtain information.
c. Document only in the EHR.
d. All of the above
e. a and b

C. Working with Health Records


1. Which of the following is considered a category used for organizing information in a POR
system?
a. Database
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records

b. Problem list
c. Treatment plan
d. Progress notes
e. All of the above

2. Which of the following is an example category used in an SOR system?


a. Progress notes
b. Laboratory
c. Database
d. Radiology
e. a, b, and d

Correct the following entries as would be done in the health record. Then rewrite the entries
correctly. Handwritten corrections are acceptable on these exercises.

3. The correct date of the appointment below was October 12, 20XX. 10-21-20XX 1330 Patient
did not arrive for scheduled appointment. P. Smith, RMA
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. The patient stated that the chest pain began 2 weeks ago.
1-31-20XX 10:00 am Patient complained of chest pain for the past 2 months. No pain noted in
arms. No nausea. Desires ECG and bloodwork to check for heart problems. R. Smithee, CMA
(AAMA)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Document the following exercise.


5. Eric Robertson canceled his surgical follow-up appointment today for the third time.
Document this information.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records

E. Filing Methods
Using alphabetic filing, place the names below in correct alphabetic order with the last name
first.
1. Using alphabetic filing, place the names below in correct alphabetic order.
Cassidy Kay Hale 1. _______________________
Candace Cassidy LeGrand 2. _______________________
Taylor Ann Jackson 3. _______________________
Anton Douglas Conn 4. _______________________
Mitchel Michael Gibson 5. _______________________
Lorienda Gaye Robison 6. _______________________
LaNelle Elva Crumley 7. _______________________
Allison Gaile Yarbrough 8. _______________________
Sarah Kay Haile 9. _______________________
Marie Gracelia Stuart 10. _______________________
Karry Madge Chapmann 11. _______________________
Randi Ann Perez 12. _______________________
Cecelia Gayle Raglan 13. _______________________
Sarah Sue Ragland 14. _______________________
Riley Americus Belk 15. _______________________
Starr Ellen Beall 16. _______________________
Mitchell Thomas Gibson 17. _______________________
George Scott Turner 18. _______________________
Winston Roger Murchison 19. _______________________
Sara Suzelle Montgomery 20. _______________________
Tamika Noelle Frazier 21. _______________________
Alisa Jordan Williams 22. _______________________
Alisha Dawn Chapman 23. _______________________
Bentley James Adams 24. _______________________
Montana Skye Kizer 25. _______________________
Dakota Marie LaRose 26. _______________________
Robbie Sue Metzger 27. _______________________
Thomas Charles Bruin 28. _______________________
Percival “Butch” Adams 29. _______________________
Carlos Perez Santos 30. _______________________
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records

2. Using terminal filing, place the numbers below in the correct order.
01-64-22 a. ____________________
72-55-20 b. ____________________
44-41-20 c. ____________________
17-41-20 d. ____________________
56-42-21 e. ____________________
91-88-21 f. ____________________
15-24-22 g. ____________________
82-49-20 h. ____________________
08-94-21 i. ____________________
24-42-22 j. ____________________

Workplace Applications
1. Dr. Martin wants to be sure the Walden-Martin Family Medical (WMFM) Clinic is
meeting all of the requirements for meaningful use that are specified in the HITECH Act.
He has asked Susan to put together a list of what WMFM Clinic should be doing to meet
those requirements. What would be on Susan’s list?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. Susan has been learning about the various EHR systems available. She has also been
learning about the need to back up to protect the information stored in the EHR. Susan
has asked the office manager at WMFC how the EHR is backed up at their facility. The
office manager states that they currently use an external hard drive, but would like to
look more closely at other options. She asks Susan to determine what other options are
available. Write a brief description of each of the options below:
a. External hard drive:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
MOA115 Medical Records and Insurance
Week 1 Assignment – Health Records

b. Full server backup:


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

c. Online backup system:


________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Common questions

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A medical assistant should ensure patient privacy by following HIPAA guidelines, employ effective interviewing techniques for accurate data collection, and document consistently and accurately into the EHR. This involves being attentive to detail, maintaining objectivity, and ensuring that all records are complete and updated in real-time.

A medical release form generally includes the patient's personal details, description of the information being disclosed, the purpose of release, the person or entity receiving the information, and expiration date of the release. It must be signed by a patient or their authorized representative when their protected health information needs to be shared with parties outside the healthcare provider's office, to ensure compliance with privacy laws.

Proper documentation is crucial for legal protection, clinical decision-making, and continuity of care. Corrections must be clearly marked to avoid any misinterpretation or accusations of tampering. Failing to maintain accurate documentation can lead to potential legal consequences, compromised patient safety, and undermined trust between patients and providers. It is essential to follow clear, standardized protocols for documenting corrections.

Alphabetic filing orders records by the patient's last name, which is straightforward for small-scale operations but may become cumbersome with larger volumes. Terminal digit filing organizes records by the last set of numbers in the record number and is advantageous in high-volume settings, as it evenly distributes records, minimizes congestion, and optimizes space utilization.

Accurate health records are essential for providing quality medical care, offering legal protection for care providers, supplying necessary information for clinical decisions, and facilitating research analytics. Inaccuracies can lead to misdiagnoses, medical errors, compromised patient safety, increased liability risks, and flawed research data. Each of these outcomes can have serious repercussions for patient health and institutional integrity.

The POR system categorizes information into a database, problem list, treatment plan, and progress notes, organized around specific patient problems. The SOR system, in contrast, organizes information based on the source of data, such as laboratory reports, radiology data, and progress notes, focusing on the origin rather than patient problems. These differences influence how healthcare providers access and manage patient data.

Subjective data include symptoms reported by the patient, such as complaints of headaches and feelings of nausea. Objective data comprise observations and measurements made by healthcare providers, such as blood pressure readings, bloated stomach, and visible bruises. Accurate categorization into these types helps in comprehensive analysis and treatment planning.

Alternative EHR backup options include full server backup, which saves entire systems and offers comprehensive recovery capabilities, and online backup systems that provide offsite data storage with the advantage of remote access and automation. Cloud storage solutions are increasingly favored for their scalability and security, offering advanced encryption and redundancy to protect data integrity.

Healthcare facilities can ensure compliance with meaningful use by maintaining certified EHR technology, implementing clinical decision support rules, tracking key clinical conditions, and engaging patients and families in their healthcare management. Ensuring adequate staff training and securing robust data protection practices are also essential components. These measures collectively enhance the quality, safety, and efficiency of healthcare services.

The Notice of Privacy Practices (NPP) informs patients about their rights to privacy under HIPAA, detailing how their medical information may be used and disclosed by the healthcare provider. It ensures transparency and builds trust between patients and providers by educating patients about their rights and the provider's responsibilities. Receiving this information is crucial as it allows patients to make informed decisions about their health data.

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