Exam 11: Medical Records and Documentation

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

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

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

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

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?

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

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

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.

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.

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

Recording information in the medical record is called ____.

A medical record received from another physician should be ___.

The reason a patient's record should not be sent by fax machine is that ____.

A patient's illness and reason for this visit to the physician are found in the ____.

Kenneth is preparing copies of X-ray and lab results from Mrs. Vendel's chart to be mailed to another physician's office. He tells you that he thinks this is a waste of time, but Mrs. Vendel called and requested that the records be sent to the other physician's office for a second opinion. How should you respond?

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

Important information about a patient's medical history and present condition is found in the ____.

Patient X-ray and lab tests should be placed in the medical record according to facility policy, but always in reverse ________ order.

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

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