ensure that the physician has initialed all reports before they are inserted into the chart.
When adding medical records to a patient's chart, you should?
100
clear
one of the C's of charting includes:
100
Fischer, William
What is of the following names, which would come first in alphabetic filing?
100
chronological order
What is the method of filing used when documentation is placed in order based on the date of occurrence is:
100
disk
What is a back up file to a computer medical record is called the:
200
SOAP
The most common method of documentation for a patient medical record is:
200
Plan for tests and treatments
The "P" in the SOAP method of charting includes:
200
Of it is not documented, it was not done
What is The "golden rule" in the documentation is the following:
200
Release a copy of the medical record, not the original
What is An important rule for releasing medical records is:
200
conditioning
What is the process of gathering all chart items together and preparing then for filing by removing loose pieces of paper clips and replacing them with staples is known as:
300
831140, 381249, 105449, 943650
When filing numerically using the terminal digit filing method, what is the proper sequence for filing these numbers: 381249, 831140, 105449, 943550
300
Office visit entries from June 2010 would be in front of visits from December 2008
If filing reverse chronologic order, which of the following is in the correct order sequence.
300
location of practice
What is determining the organization of the medical record and sequence of filing is dependent on the following factors EXCEPT?
300
closed
What is if a patient is not expected to return ti the practice because he or she has moved away, the patient's record would be classified as:
300
HIPPA
What is the federal government policy that sets standards for electronic transmission of medical information is included in the act adopted in 1996 called:
400
When a last name has a hyphen, it is filed as if the hyphen were not there.
Which of the following is a true statement regarding guidelines for alphabetic filing.
400
date and sign the correction
What is the proper procedure to correct an error in a patient's chart is to:
400
Patient's present illness
What is The database component problem-oriented medical records (POMR) includes what information?
400
physician
What is the patient's medical record contained within the patient's file are the property of the:
400
delay in filing test results
What is to avoid legal and ethical issues, patients' medical records should be properly maintained, which includes all of the following EXCEPT:
500
outgiude
When a paper medical record is in use, a folder inserted on the shelf on a place of the medical record file is a (n):
500
alphanumeric filing
What is a system of filing made of combinations of numbers and letters is:
500
statue of limitations
What is The term used to describe the legal length of time regarding storage of medical and business records is:
500
Treat hyphenated names as two units
What is indexing rules for alphabetic filing include the following except:
500
Blood pressure reading
What is when using the SOAP method of charting, which of the following belongs to the O section?