Exam 11: Medical Records and Documentation

All health records are considered the property of the licensed practitioner or the medical facility; however, the information they contain belongs to the patient and is regarded as ________. The patient's written consent is required to release them.

The best way to make sure the licensed practitioner sees a patient's X-ray report before filing it is to _____.

Which of the following information is found on the patient registration form?

The type of documentation that provides an orderly series of steps for dealing with any medical case is ____.

Benise is a new medical assistant in the clinic. She has little experience, but she has a great attitude and she is determined to do the job correctly. As you pass by, you notice that she is frowning at a patient's medical record. You ask if you can help, and she tells you that the patient has moved across town to take a new job, so all of his address, phone number, employment, and health insurance have changed. Benise is trying to figure out how to make all of those changes to the record. "It just won't fit!" she exclaims. What advice might you offer to Benise?

When you document according to a numbered problem, the chart is arranged by the ________-oriented medical record system.

The ________ summary form generally includes a summary of the reason the patient entered the hospital; tests, procedures, or operations performed in the hospital; medications administered in the hospital; and the disposition or outcome of the case.

Audits that are done by medical staff before patient billing is submitted are ____.

Which of the following is necessary to release a patient's record to the patient's insurance company?

The primary problem for which a patient comes to see the physician is known as the ________ complaint.

The Notice of _______________ is a written document that provides patients with information on how their personal health information is used and protected.

When you release medical information, always send ________ unless the record will be used in a court case, in which case you should send the original records.

Everything that is entered into the patient's health record by the medical assistant must be dated and ___________.

All information should be entered in the record at the time of a patient's visit, not days, weeks, or months later. This is called ____.

The O section of SOAP documentation is ____.

Information in the medical record provides a plan to follow for the ________ of patient care.

The patient ________ form contains legal, financial, and demographic information about the patient.

The medical assistant is responsible to the ________ and the physician for both the medical and administrative procedures performed and the accurate recording of those procedures.

Which of the following is appropriate when correcting a medical record?

In the problem-oriented medical record (POMR), which of the following includes a record of the patient's history, information from the initial interview, and any tests?