Exam 11: Medical Records and Documentation

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?

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

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

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 ____.

A guideline for releasing medical information is to ____.

What color ink is preferred for handwritten documentation in a patient's medical record?

Patient records, also known as ________, contain important information about a patient's medical history and present condition and serve as communication tools as well as legal documents.

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

Patient records are used in medical research ____.

Information corrected or added some time after a patient's visit can be regarded as ____.

In addition to being essential documents for patient care management, patient records are used for ____.

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 ____.

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

The A section of SOAP documentation includes ____.

A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the ____.