Exam 11: Medical Records and Documentation

Which of the following organizations reviews patient charts to monitor whether the care provided and the fee charged meet accepted standards?

In the CHEDDAR format of documentation, the C section includes

The most appropriate way to terminate an initial interview with the patient is ____.

The specific information required of a population that must be obtained when a new patient makes an appointment with the office is ________.

The O section of SOAP documentation is ____.

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

The best place to interview a patient is ____.

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

An example of a patient symptom is ____.

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

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.

The section of a patient medical history form that contains the patient's description of the current condition or complaint is called the _________of present illness section.

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

The role the medical assistant plays in patient education is to explain ____.

Subjective or internal conditions felt by the patient are ____.

To reduce confusion in medical records, ________ are being used less often, except for those that are very clear in meaning.

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

If an employee of the practice records information inappropriately or inaccurately in a patient's chart, in a court of law, the ________ and the employee are held responsible.

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

A physical examination form that is used during an "oral examination" to identify any signs or symptoms the patient may be experiencing or reveal information about an illness or condition is called a review of _________ or ROS.