1-5
All information should be entered in the record at the time of a patient's visit, not days, weeks, or months later. This is called ____.
due course
The most appropriate way to terminate an initial interview with the patient is ____.
"Is there anything else you would like the doctor to know?"
"The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation
clarity
Internal audits are done BY?
medical staff on random records.
When do most states consider children to be adults with the right to privacy?
Age 18
. In the CHEDDAR format of documentation, the C section includes
presenting problems.
The type of documentation that provides an orderly series of steps for dealing with any medical case is ____.
soap
The first document found in a patient's financial record is the ____.
patient registration form
Audits that are done by medical staff before patient billing is submitted are ____.
prospective internal audits
. The role the medical assistant plays in patient education is to explain ____.
management of the patient's condition as outlined by the physician
Patient records are used in medical research ____.
for data regarding patient responses and side effects
the following organizations reviews patient charts to monitor whether the care provided and the fee charged meet accepted standards?
The Joint Commission
The P section of SOAP documentation is ____.
the plan of action
In the problem-oriented medical record (POMR), which of the following includes a record of the patient's history, information from the initial interview, and any tests?
Database
The S section of SOAP documentation is ____.
data that comes directly from the patient
The appropriate way to delete information on a medical record is to ____.
draw a line through the original information so it is still legible
When is it appropriate to send the original documents in a patient's chart?
When the record is subpoenaed for a court case
The best way to make sure the physician sees a patient's X-ray report before filing it is to _____.
have the physician initial the report
The A section of SOAP documentation includes ____.
the diagnosis of impression of a patient's problem
One of the most important duties of a medical assistant is to ____.
fill out and maintain accurate and thorough patient records
Important information about a patient's medical history and present condition is found in the ____.
patient's chart
The purpose of having a patient sign an informed consent form is to ensure that the ____.
patient understands the treatment offered and the possible outcomes
The O section of SOAP documentation is ____.
data that comes from examination results and from the physician
Objective or external factors that can be seen or felt by the physician or measured by an instrument are called ____.
signs
A patient's illness and reason for this visit to the physician are found in the ____.
patient medical history