Exam 11: Medical Records and Documentation

You should make a(n) ________ to medical records in a way that does not suggest any intention to deceive, cover up, alter, or add information to conceal a lack of proper medical care.

Medical records must be written neatly and legibly, contain up-to-date information, and present a(n) _______, professional record of a patient's case.

Recording information in the medical record is called ____.

The right to sign a release-of-records form for a child when the parents are divorced belongs to ____.

One of the most important duties of a medical assistant is to ____.

When is it appropriate to send the original documents in a patient's health record?

A guideline for releasing medical information is to ____.

In legal terms, medical records regarded as ____ may damage a physician's position in a lawsuit.

A(n) ________audit is frequently done by a third party if fraudulent billing is suspected.

Complete, thorough ________ ensures that the physician will have detailed notes about each contact with the patient and about the treatment plan, patient responses and progress, and treatment outcomes.

Part of creating timely and accurate records is maintaining a(n) ________ tone in your writing.

The first document found in a patient's financial record is the ____.

In conventional or ________-oriented medical records, patient information is arranged according to who supplied the data.

The P section of SOAP documentation is ____.

Objective or external factors that can be seen or felt by the practitioner or measured by an instrument are called ____.

When you are in doubt about who is ________ to give consent to release information, you should ask your supervisor before releasing confidential medical records.

Dr. Girardi tries to call a patient to explain test results, but the patient does not answer the phone, and Dr. Girardi does not leave a message because he prefers to discuss the results with the patient. As the medical assistant, it is your job to ____.

Internal audits are done

A(n) ________ is an examination and review of patient records.

The A section of SOAP documentation includes ____.