when adding medical records to a patients chart you should
ensure that the physician has intitialed all reports before they are inserted into the chart
100
one of the cs of charting includes
clear
100
of the following patients names which would come first alphabetic filing
fischer, william
100
the method of filing used when documentation is placed in order based on the date of occurence is
chronologic order
100
a backup file to a computer medical record is called the
disk
200
the most common method of documentation for a patient medical record is
SOAP
200
the P in the SOAP method of charting includes
plan for tests and treatments
200
the golden rule in documentation is the following
if it is not documented it was not done
200
an important rule for releasing medical records is
release a copy of the medical record not the original
200
the process of gathering all chart items together and preparing them for filing by removing loose piees of tape or paper clips an dreplacing them with staples is known as
conditioning
300
when filing numerically using the terminal digit filing method what is the proper squence for filing these four numbers
381249. 831140.105449.943550
831140.381249.105449.943650
300
if filing using reverse chronologic order which of the following is in the correct sequence
office visit entries from june 2010 would be in front of visits from december 2008
300
determining the organization of the medical record and sequence of filing is dependent on the following factors except
location of practice
300
if a patient is not expected to return to the practice because he or she has moved away the patients record would be classified as
closed
300
the federal government policy that sets standards for electronic transmission of medical information is included in the act adopted in 1996 called
HIPAA
400
which of the following is a true statement regarding guidlines for alphabetic filing
when a last name has a hyphen it is filled as if the hyphen were not there
400
the proper procedure to correct an error in the patients chart is to
date and sign the correction
400
the database component of problem-oriented medical records includes what information
patients present illness
400
the pages of the medical record contained within the patients file are the property of the
physician
400
to avoid legal and ethical issues patients medical records should be properly maintained which includes all of the following except
delay in filing test results
500
when a paper medical record is in use a folder inserted on the shelf in place of the medical record
outguide
500
a system of filing made of combinations of numbers and letters is
alphanumeric filing
500
the term used to describe the legal length of time regarding storage of medical and business records is
statute of limitations
500
indexing rules for alphabetic filing include the following except
treat hyphenated names as two units
500
when using the SOAP method of charting which of the following belongs to the O section