Cert Quiz 11

heyguysitsclaire's version from 2016-03-10 21:14


Question Answer
When adding a laboratory report to a patients chart, you shouldensure that the physician has initialed all reports before they are inserted into the chart
The most common method of documentation for a patient medical record isSOAP
Which of the following is a true statement regarding guidelines for alphabetic filingwhen the last name has a hyphen, it is filed as if the hyphen were not there
When a paper medical record is in use, a folder inserted on the shelf in place of the medical record is a(n)out guide
One of the Cs of charting includesclear
The P in the SOAP method of charting includes plan for tests and treatments
If filing using reverse chronological order, which of the following is the correct sequenceoffice visit entries from December 2014 would be before visits from June 2014
The proper procedure to correct the error in a patients hard copy chart is todate and sign the correction
A system of filing made from combinations of numbers and letters isalphanumeric filing
Of the following patient names, which would come first in alphabetic filingFischer. William
The golden rule in documentation is which of the followingif it is not documented, it was not done
Determining the organization of the medical record and sequence of filing is dependent on the following factors exceptlocation of practice
The database component of problem oriented medical records includes what informationpatients present illness
The term used to describe the legal length of regarding storage of medical and business records isStatute of Limitations
The method of filing used when documentation is placed in order based on the date of the occurence ischronological order
An important rule for releasing hard copy medical records isrelease a copy of the medical record, not the original
If a patient is not expected to return to the practice because he or she has moved away, the patients file would be classified as closed
The pages or screens of the medical record contained within the patients file are the property of the physician
Indexing rules for alphabetical filing include the following excepttreat hyphenated names as two units
One method of backing up a file to a computer medical record is called thedisk
The process of gathering all chart items together and preparing them for filing by removing loose pieces of tape or paper clips and replacing them with staples is known asconditioning
The federal government policy that sets standards for electronic transmission of medical information is included in the act adopted in 1996 calledHIPAA
To avoid legal and ethical issues, patients medical records should be properly maintained, which includes all of the following exceptdelay in filing test results
When using the SOAP method of charting, which of the following belongs to the O sectionblood pressure reading
SOMR refers tosource oriented medical record
When a medical record or patient file is audited, it isexamined