Content:
The area was prepared and draped in the usual sterile manner.
What type of report would this be transcribed? Progress note Discharge summary History and physical Operative report.
In which report would the phrase "cranial nerves are intact" likely be documented? Autopsy Operative report Pathology report History and physcial.
There is marked tenderness over McBurney point.
Under what physical examination subheading would this observation be transcribed? HEENT Chest Abdomen Neurologic.
Specimens sent for frozen section reveal a desmoplastic stromal response.
Under which report heading would this statement be found? PHYSICAL EXAMINATION INVESTIGATIONS DIAGNOSIS MICROSCOPIC DESCRIPTION.
What is the purpose of date and time stamping in medical transcription? To allow reimbursement To help create an audit trail To indicate the date treatment was provided To identify the transcriptionist.
Which expression is included in the record to meet HIPPA security requirements? AXIS II T1NXMX T: 12/31/11, 1500 Dictated but not read.
Which sentence would require editing by the medical transcriptionist? Both the patient and I received the laboratory results. Both I and the patient received the laboratory results. Laboratory results were forwarded to the patient and I. Laboratory results were forwarded to the patient and me.
Which dictated sentence requires editing by the transcriptionist? He complains of pain in the right shoulder, inability to sleep at night, and difficulty raising his arm. He complains of having right shoulder pain, being unable to sleep at night, and having difficulty raising his arm. He complains that he has pain in the right shoulder, is unable to sleep at night, and has difficulty raising his arm. He complains of right shoulder pain, unable to sleep at night, and difficulty raising his arm.
Which sentence contains slang that requires editing by the transcriptionist? I requested a crit level on this patient. This physician carried out an exam on the patient. Before the procedure, a sterile prep was performed. The lab results showed elevated eos.
Which contains transposed values? Hemoglobin 42, hematocrit 14. WBC 8500 and RBC 5.2. The pH is 5.2. Specific gravity is 1.020. Normal differential showing 50% segs and 1% eos.
DICTATED: The patient saw Dr. Arif Shah for a 2nd opinion.
The dictator does not spell the doctor's name. Which is the best way to transcribe the sentence? The patient saw another doctor for a 2nd opinion. The patient saw Dr. _____ for a 2nd opinion. The patient saw Dr. R. F. Shaw for a 2nd opinion. The patient saw Dr. (sounds like R. F. Shaw) for a 2nd opinion.
The physician is dictating the results of an MRI into an office note. He is interrupted in the middle of a sentence. When he returns, he does not continue with the MRI, but begins dictating recommendations. What is the correct action to take? Stop transcribing, delete the report, send the audio file back to the main queue, and begin another job. End the MRI dictation at the last complete sentence, continue with the remainder of the report, and submit the report. End the MRI dictation in mid-sentence as dictated, continue with the remainder of the report, and submit the report. End the MRI dictation mid-sentence as dictated, continue with the remainder of the report, and flag the report for the physician.
What does HIPPA stand for? Health Insurance Portability and Access Act. Health Information Portability and Accountability Act. Health Insurance Portability and Accountability Act. Health Information Portability and Insurance Act.
Under HIPPA definition, what does PHI stand for? Protected Health Information Patient Health Information Priviledged Health Information Private Health Information.
According to HIPPA, PHI includes information in what form? On paper On paper and electronically transmitted On paper, electronically transmitted, and orally transmitted Electronically transmitted and orally transmitted.
Which would be a violation of the HIPPA privacy rule? Releasing information relating to patient's care to a third-party insurance billing company Disclosing information about an individual's health in a phone call between physicians providing care for the same patient Releasing information about a patient's health status to public health authorities Using a de-identified health record for clinical study or statistical research.
Which individual is considered an accountable party under the HIPPA rule? An employee of a covered entity An employee of a transcription service A business associate of a covered entity An employee of a federally funded healthcare facility.
Which characteristic determines that an offshore transcription service is considered a business associate under HIPPA? It employs US-based transcriptionists It contracts directly with a covered entity It subcontracts to a US-based business associate It performs transcription services involving US-based patients.
Which is a precaution recommended in sending PHI by fax? Transmit faxes only at night, when offices are empty Transmit only de-identified health information Transmit using pre-programmed client fax numbers Transmit faxes only after notifying the recipient by phone that the fax is coming.
What is recommended for fax machines transmitting PHI? Use them only for transmitting PHI Locate them in a secured area Use only certain models especially designed for PHI Allow only one designated individual to use them.
Under the HIPPA security rule, when is it recommended to encrypt health information? Only when downloading information Only when uploading information When transmitting information over some networks When transmitting information by fax.
What authentication practice is considered dangerous by Joint Commission? Electronic signature Autosignature Handwritten signature Handwritten initials.
What is the Joint Commission's position on authentication of the healthcare record? Any credentialed healthcare provider may appropriately authenticate any health record Authentication cannot be delegated to anyone other than the author of the record Authentication may be delegated to the proper ancillary medical personnel The author of the record may assign responsibility for document accuracy to the medical transcriptionist.
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