Taking the place of a written prescription is known as
What is e- prescribing
100
The medical History form in patient medical record is completed by the
What is the patient
100
What is one pitfall that should be avoided in regards to documentation?
What is procastination
100
What is the newest component used today to complete transcription and authenticate records?
What is Voice Recognition Technology
100
The term used to describe the legal length of time regarding storage of medical and business records is:
What is statute of limitations
200
Giving instructions to patient or helping them clarify information is an example of
What is patient education
200
database, problem list, plans, and progress notes are part of A. POMR B. SOMR
What is POMR
200
What is the section of the medical record that contains letters written about the patient from an assessment made by a specialist?
What is consultation reports
200
Any system that arranges names or topics according to the sequence of the letters in the alphabet
What is alphabetical filing
200
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
300
Notes on the POMR are charted using the SOAP method. “SOAP” stands for
What is What is subjective, objective, assessment, plan
300
What is way that a provider discovers the reason for the patient's office visit?
What is Chief Complaint
300
What is the section of the chart in which you would find a biopsy study?
What is Lab Reports
300
What is a file that is used to hold the place of a chart that is pulled
What is Out Guide
300
If a patient is not expected to return to the practice because they moved away, the patient's record would be classified as:
a. active b. inactive c. closed d.open
What is closed
400
The process of removing active files to inactive status is called
What is purging
400
in reverse chronologic order which would be filed first
laboratory test results dated March 23, 2011 or one dated May 25, 2011
What is Lab test dated May 25 ,2011
400
What is the section of Medical Records ,that a Lipid Panel and Chem 21 report be filed in?
What is Lab section
400
The _________ rule , gives individuals a fundamental new right to be informed of the privacy practices of their health plans.
What is HIPAA Privacy Rule
400
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:
a.inspecting b.indexing c. conditioning
What is conditioning
500
What is a notice of how a patient's medical information will be used should be given to every patient and a form explaining that the patient received the information should be signed and filed in the chart?
What is Notice Of Privacy Policies (NPP)
500
What is a follow-up note for a previous office visit , in patient medical record called ?
What is Progress Note
500
Which of the following is not found in a flow sheet?
A.Blood Pressure B. Total Cholesterol C. HbA1c D. Drug Allergies
What is drug allergies
500
A method of filing in which a report is laid on top of the older report, resembling shingles of a roof
What is shingling
500
The date base component of POMR includes what information?
a. drug allergies b. patient's present illness c.prescriptions
d.referrals