Exam 4: Medical Documentation and the Electronic Health Record

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Explain the methods for disposing of both paper and electronic records.

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Criteria used by insurance companies when making decisions to limit or deny payment in which medical services or procedures must be justified by the patient's symptoms and diagnosis are called ____________________.

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Match each of these types of medical services to the correct definition. -Care provided during a life-threatening condition in the hospital emergency department.

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Physicians are required to use the documentation guidelines developed by the AMA and CMS.

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Match each of these terms, as they are used in a medical office, with the correct definition. -Symptom/pain and other changes that are noted when the symptom/pain occurs.

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Match these types of physicians with the description of the services each provides. -Provider who renders a service to a patient.

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When a patient receives similar services by more than one physician on the same day, it is called ____________________ care.

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The official American Hospital Association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the"

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In dealing with managed care plans, a referral is

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Match each of these types of medical services to the correct definition. -Transfer of the total care of a patient from one physician to another.

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A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as

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The SOAP in patient medical record charting may be defined as

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Match these types of physicians with the description of the services each provides. -Provider who is the medical staff member legally responsible for the care and treatment given to a patient.

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Match these types of physicians with the description of the services each provides. -Individual who directs the selection, preparation, or administration of tests, medications, or treatment.

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