Doc Docs
What method is the most common system for outlining and structuring chart notes for a medical record?
SOAP
Passwords
What is the best measurement of the quality of care given to a patient?
The medical record
All medical records should be kept until....
The possibility of a malpractice lawsuit has passed
The need to save space in many offices has made __________ files popular
Open-Shelf
A technology being used in medical and other offices for data input
Voice Recognition Software
The ________ findings in a SOAP record are the physician's examination of the patient.
Objective
Getting rid of information not recoverable is ___ good business practice.
Not
Medical Records must be treated as...
Legal Documents
When a patient has died, moved away, or terminated their relationship with the physician, the file is considered to be...
Closed
Rigid dividers placed at the end of a section of files to indicate where a new section or category of files begins.
Guides
Computer programs that apply the computer’s capabilities to specific uses, such as word processing, graphics, database management, and spreadsheets.
Application Software
The first part of the CHEDDAR method
Adding missing omitted information into an EHR is an example of a _________
Late Entry
EHR stands for...
Electronic Health Record
Records that have been closed an those that must be kept permanently are said to be in _______ storage, a storage area separate from the area where active files are kept
Dead
The placement of related material alphabetically by
subject categories
Subject Filing
Medical Transcriptionalists must also be able to do this with a high level of proficiency
Proofread Medical Docs
In the patient EHR, the physician is easily able to view a list of all the patient's current and previous medical conditions... Which format is the office using?
POMR
EHRs utilize a ________ where date is stored and updated with each interaction
database
EMR stands for...
Electronic Medical Record
When medical data is destroyed, the practice must maintain a ....
Record of destruction
indicates where the original material is filed and where in the files other copies may be found.
Cross-Reference Sheet
Excel is an example of what type of software?
Spreadsheet program
The SOAP method is used in the _________ section of the POMR method
Master Problem List
Offices using electronic medical record entry methods shouyld affix what to all chart entries?
electronic Signature
Every interaction or information about a patient must be placed in a _________ and placed in the EHR
Chart Note
Providers who receive payment from Medicare must retain records for ____ years
5
The second step in the Filing process
Indexing
This is the term used for designing the work environment to meet the needs of the human body
Ergonomics