Mod A Unit 3 Lab Review

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The purpose of medical records is to provide evidence of

all of the above(patient assessment,intervention,communication)

The medical record

serves as a legal record documenting the planning and care that the patient received

Documents stored in the medical record

are stored in chronological order(most recent first)

The documents in problem-oriented medical records are

organized according to the patient's particular problems

The documents in source-oriented medical records are

grouped by the type of services that were provided

POMR stands for

problem-oriented medical record

Notes on the POMR are charted using SOAP method. "SOAP" stands for

subjective,objective,assessment,plan

Using the letter "O" in SOAP, information documented in this section would include

information that can be observed or seen

In order for the medical office to submit forms for the patient to the insurance company, the patient usually needs to

sign a release form

Using the letter "S" in SOAP, information documented in this section would include

information provided by the patient

If the office is using a color-coded system, the color code should be

known by everyone in the office

To indicate that a record has been removed from the file cabinet, the medical assistant uses

an out guide

In the alphabetic system, each name is broken down into

units

The second unit in alphabetic filing is the patient's

first name

Using the letter "A" in SOAP, information documented in this section would include

impressions that the physician has about the cause of the patient's symptoms

Using the letter "P" in SOAP, information documented in this section would include

plan for the patient's treatment

The patient making the statement, " I feel like someone is pounding nails into my head," would have this statement documented in the SOAP format under

S

diagnosis tests, medications, and treatments to be started are documented in the SOAP format under

P

The physician's preliminary diagnosis is documented in the SOAP format under

A

The medical record is owned by

the physician

Information in the medical record is owned by

the patient

The most common method of filing is

alphabetic

Tickler files should be

organized and cheked

Using the alphabetic system of filing, "The Harris Office Supply company" would be filed under

H

Which of the following names would be filed first???

De La Mare, Winston

The_____process is the determination of how a record will be filed

indexing

In alphabetical filing, a______name is used as the key indexing unit

last

Which of the following names would be filed before Mary Lynn Sommers?

Mary Samuels

Which of the following names would be filed first??

J. Jackson

Which one of the following would be filed first?

President Elson anderson

______filing organizes a number by the final digits of the number

None of the above

A file is "______" when a checkmark is placed on the document indicating it should be filed

released

Inactive files are the files of a patient who has not visited the practice in_______

a time span set by the practice

A_____is a reminder aid that organizes events by date

tickler file

which one of the following files is NOT a standard form included in a patient record?

Birth certificate

If an established patient sees the physician for a______, a new file must be made because the patient's complete health information would not be made available to an employer

work-related injury

_____regulations require providers to issue a written statement to each patient telling them about how the patient's health information may be used

HIPAA

When a file for a new patient is being created, the first step in the procedure is to _______

obtain and review a patient information form

If two patients have the exact same name, which of the following would determine which patient's file is filed first?

Date of birth

A______medical record is arranged according to the patient's health complaint

POMR

"My ankle hurts" is which one of the following types of information?

Subjective

Which one of the following is "objective information"?

All of the above is objective information(There is selling and bruising of the ankle and foot,. when the patient is walking to the examination on room, you notice it is painful for the patient to put weight on the foot,.The foot is hot to the touch)

All entries in a patient's record should begin with the_______

date of the encounter

When choosing a filing system, the practice needs to consider all of the following EXCEPT_____

what is esthetically pleasing

_____has established rules to assist in efficient alphabetic filing

ARMA

Which one of the following is a disadvantage to numerical filing?

It is easy to misfile

The filing system that has stationary shelves and a door cover that slides up and back into a cabinet and can hold approximately 1000 records is a______file cabinet

lateral,open-shelf

As computerization becomes increasingly sophisticated in medical offices,the use of electronic medical records is growimg in popularity and will soon become the industry standard.Which one of the following is NOT an advantage of this type of system?

There is an inability to secure all records and maintain confidentiality

___are divders of a different size and color than a file folder.They should always be used when a file is removed from the storage system

Out guides

The______filing method uses letters of the alphabetic to determine how files are arranged

alphabetical

____is a method of arranging files using straight numbers

Numerical filing

_____is the process of determining how a record will be filed

indexing

Words(s) that describe the content's name or subject matter on a label is(are)_______

caption

_____is a chart that uses dividers to separate the different types of patient information

Source -oriented format

A type of chart format that divides each patient problem into subjective data, objective data,assessment, and plan for treatment is_______

SOAP

A_____is entered into the patient's record and is used to update the status of the patient's health. These are added to the patient's chart each time the patient visits the office

progress note

The physician owns the medical record, but the patient owns the information

True

When might a medical assistant use a patient's date of birth as an indexing unit for filing?

When two patients have the same name and same address

Which one of the following names would be filed first?????

Edward Green III

Which one of the following names would be filed second?

Cleo Gonzales Esq

Which one of the following names would be first???????

Kimberly Edades

Which one of the following names would be filed first??????

Belinda deLarue

Professional titles and professional, numerical, and seniority suffixes are always indexed________

last

which one of the following is a charting "DON'T"?

Chart anything you did not see or do

Which one of the following is NOT part of the decision when selecting a filing system?

all of the above would be considered when selecting a filing system(selection of supplies,types of storage equipment, available space)

In which filing are records more protected in case of fire?

Vertical-drawer

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