How can we help?

You can also find more resources in our Help Center.

66 terms

Mod A Unit 3 Lab Review

STUDY
PLAY
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