medical Records
Patient intake forms include?
HIPAA notice, HIPAA release of records, patient registration form
In the SOAP note documentation format, the section where a clinician records measurable data like vital signs and lab results is designated by this letter.
What is 'O' (Objective)?
In an alphabetic filing system using a patient's full name, this component of the name is designated as Primary Indexing Unit #1.
What is the Last Name (Surname)?
What is the period of retention for the following- Care of a minor?
Records must be kept until the child is at least 21 years old
A-An
without
SOAP
The most common method of documentation for a patient medical record is:
This type of medical record system organizes patient data sequentially by date, placing the newest documents at the top or front of the chart.
What is a Chronological Medical Record (or Source-Oriented Record)?
This filing system assigns a unique sequence of numbers to each chart and is widely used in large hospitals to maintain patient privacy.
What is Numeric Filing?
This term refers to records belonging to patients who have not been seen by the medical practice for a specified timeframe (typically 3 to 5 years).
What are Inactive Records?
Bi/Bin
Double or two
This intake questionnaire collects details about a patient's past surgeries, family medical background, lifestyle habits, and current symptoms.
What is the Medical History Form (or History and Physical Questionnaire)?
If filing reverse chronologic order, which of the following is in the correct order sequence. Paperwork from April 2026 and June 2026
Office visit entries from June 2026 would be in front of visits from April 2026
When a physical paper chart is removed from a filing cabinet, staff must insert this placeholder item to track who took the file and when.
What is a guide?
The process of permanently removing or shredding medical records after their legal retention period has expired is called this.
What is Record Destruction (or Purging)?
With/ together
What is Co, Con, Com
List 2 of the most common types of filing units
Vertical cabinets • Lateral shelves • Shelving units • Compactable shelves • Rotary cabinets • Automated filing systems
strike out and date and sign the correction
What is the proper procedure to correct an error in a patient's chart is to:
What is indexing
Indexing is identifying the person, facility, or subject to file the document.
To comply with HIPAA security standards, paper files containing PHI must be secured behind a minimum of this many locking barriers (e.g., locked cabinet inside a locked room).
What is two locks (or two-layer physical security)?
Outside
What is Ex, Extra
How should folders be labeled?
They should be labeled with either the patient’s name or the patient’s identification number
alphanumeric filing
What is a system of filing made of combinations of numbers and letters is:
What is the purpose of color-coding folders?
Color-coding is used to make filing easier and more efficient
What is the period of retention for the following-retirement of a physician?
Records should be transferred to each patient’s new doctor.
Within
in, intra