Ensure that the physician has initialed all reports before they are inserted into the chart.
What is When adding a laboratory report to a patient's chart, you should
100
SOB
What is the most common method of documentation for a patient medical record is
100
When a last name has a hyphen it is filled as if the hyphen were not there
What is which of the following is a true statement regarding guidelines for alphabetic filling.
100
Out guide
What is When a paper medical record is in use, a folder inserted on the shelf in place of the medical record file is a(n)
100
Clear
What is One of the "Cs" of charting include
200
Plan for tests and treatments
What is The "P" in the SOAP method of charting includes
200
Office visit entries from December 2014 would be in front of visits from June 2014
What is If filling using reverse chronological order, which of the following is in the correct sequence.
200
date and sign the correction
What is The proper procedure to correct an error in a patient's hard copy chart is to
200
Alphanumeric filing
What is A system of filing made of combinations of numbers and letters is
200
Fischer, William
What is Of the following patient names, which would come first in alphabetic filing?
300
if it is not documented, it is not done.
What is The "golden rule' in documentation is the following
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
Patient presents illness
What is The database component of problem oriented medical records (POMR) includes what information?
300
statue of limitations
What is The term used to describe the legal length of time regarding storage of medical and business records is
300
chronological order
What is The method of filing used when documentation is placed in order based on the date of occurrence
400
Release a copy of the medical record, not the original.
What is An important rule for releasing hard-copy medical records is
400
closed
What is if a patient is not expected to return to the practice because he or she has moved away, the patent's record would be classified as
400
Physician
What is The pages or screens of the medical record contained within the patient's file are the property of the
400
Treat hyphenated names as two units
What is Indexing rules for alphabetic filing include the following EXCEPT
400
Disk
What is One method of backing up a file to a computer medical record is called the
500
Conditioning
What is The process of 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 known as
500
HIPAA
What is The federal government policy that sets standards for electronic transmission of medical information is included in the act adopted in 1996 called
500
Delay in filing test results
What is To avoid legal and ethical issues, patients' medical records, should be properly maintained, which includes all 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
500
Source-orientated medical record
Examined
What is SOMR refers too
When a medical record or patient file is audited it is