Exam 11: Medical Records and Documentation

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.

When do most states consider children to be adults with the right to privacy?

When should you record exam and test results?

All medical records are considered the property of the physician; however, the information they contain belong to the patient and are regarded as ________. The patient's written consent is required to release them.

Internal audits are done

The appropriate way to delete information on a medical record is to ____.

Transforming spoken notes into accurate written form is called ____.

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

Medical records include which of the following information about the patient?

Whether the medical practice uses conventional or POMR charts, you can use the ________ approach to documentation.

The purpose of having a patient sign an informed consent form is to ensure that the ____.

The P section of SOAP documentation is ____.

"The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation.

An example of a patient sign is ____.

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

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

The diagnosis made by the physician is found in which section of the CHEDDAR format of documentation?

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

The S section of SOAP documentation is ____.

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.