When adding a lab report to a patient's chart, you should:
What is ensure that the physician has initialed all reports before they are inserted in a chart
100
Which would come first in alphabetical filing?
What is Fischer, William
100
The method of filing used when documentation is placed in order based on date of occurrence is:
What is chronological order
100
The federal government policy that sets standards for electronic transmission of medical information is included in the act adopted in 1996 called:
What is HIPAA
100
To avoid legal and ethical issues, patients' MRs should be properly maintained, which does not include:
What is delay in filing test results
200
The most common meth of documentation for a patient medical record is:
What is SOAP
200
A system of filing made of combinations of numbers and letters is:
What is alphanumeric filing
200
The term used to describe the legal length of time regarding storage of medical and business records is:
What is statute of limitations
200
One method of backing up a file to a computer MR is called the:
What is disk
200
When using SOAP method of charting, which belongs to the O section?
What is blood pressure reading
300
Which is a true statement regarding guidelines for alphabetical filing?
What is when a last name has a hyphen, it is filed as if the hyphen were not there
300
The proper procedure to correct an error in a patient's hard-copy chart is to:
What is date and sign the correction
300
The date base component of POMR includes what information?
What is patient's present illness
300
Indexing rule for alphabetic filing do not include:
What is treat hyphenated names as two units
300
SOMR refers to:
What is source-oriented medical record
400
When a paper medical record is in use, a folder inserted on the self in place of medical record file is an
What is out guide
400
If filing using reverse chronological order, which is the correct sequence?
What is office visit entries from December 2014 would be in front of those from June 2014
400
Determining the organization of the medical record and sequence of filing dependent on the following factors except:
What is location of practice
400
The pages or screens of the MR contained within the patient's file are property of the:
What is physician
400
When a medical record or patient file is audited, it is:
What is examined
500
One of the "Cs" of charting includes:
What is clear
500
The "P" in the SOAP format of charting includes:
What is plan for tests and treatment
500
The "golden rule" in documentation is the following:
What is if it is not documented, it was not done.
500
If a patient is not expected to return to the practice because they moved away, the patient's record would be classified as:
What is closed
500
The process for gathering all chart items together and preparing them for filing by removing loose pieces of tape or paper clips and replacing them with staples is: