1
2
3
4
5
100
The most common method of documentation for a patient medical record is
What is SOAP
100
One of the C's of charting includes
What is clear
100
When a paper medical record is in use a folder inserted on the shelf in place of the medical record file is a
What is Outguide
100
The "P" in the soap method of charting includes
What is Plan for tests and treatment
100
Of the following patient name which would come first in alphabetic filing
What is Fischer, William
200
When adding edical records to a patient chart you should
What is to ensure that the physician has initialed all reports before they are inserted into the chart
200
When filing numerically using the terminal digit filing method what is the proper sequence for filing these four numbers Which of the following is a true statement regarding guidelines for alphabetic filing
What is 831140, 381249, 105449, 943650 What is When a last has a hyphen it is filed as if the hyphen were not there
200
Determining the organization of the medical record and sequence of filing is dependent on the following factors except
What is Location of practice
200
The "golden rule" in documentation is the following
What is If it is not documented it was not done
200
The database component of problem-oriented medical records (POMR) includes what information
What is Patient's present illness
300
An important rule for releasing medical records is
What is Release a copy of the medical record not the original
300
The pages of the medical record contained within the patient's file are the property of the
What is Physician
300
The term used to describe the legal length of time regarding storage of medical and business records is
What is Statue of limitation
300
If filing using reverse chronologic order which of the following is in the correct sequence
What is Office visit entries from June 2010 would be in front of visits from December 2008
300
If a patient is not expected to return to the practice because he or she has moved away the patient record would be classified as
What is Closed
400
A backup file to a computer medical record is called the
What is disk
400
Indexing rules for alphabetic filing include the following except
What is Treat hyphenated names as two units
400
The method of filing used when documentation is placed in order based on the date of occurrence is
What is Chronologic order
400
The federal government policy that sets standards for electronic transmission of medical information is included in the act adopted in 1996 called
What is HIPPA
400
When using the soap method of charting which of the following belongs to the O section
What is Blood pressure reading
500
The process of gathering all chart items together and preparing the for filing by removing loose pieces of tape or paper clips and replacing them with staples is known as
What is Conditioning
500
The proper procedure to correct an error in an patients chart is to A system of filing made of combinations of numbers and letters is
What is Date and sign the correction What is Alphanumeric filing
500
SOMR refers to
What is Source-oriented medical record
500
When a medical record or patient file is audited it is
What is Examined
500
To avoid legal and ethical issues patients medical records should be properly maintained which includes all of the following except
What is Delay in filing test results
M
e
n
u