Fordney Chapter 4: Medical Documentation

Study guide, multiple choice
Preservation of health records is governed by:
State and local law
A review of patient records done before billing is submitted is called:
Which of the following cases should not use fax transmissions:
Transmission of documents relating to information on sexually transmitted diseases, any routine transmission of patient information, Transmission of documents relating to alcohol treatment.
How should an entry in a patient's medical record be corrected:
Cross out the incorrect entry, substitute the correct info, date and initial the entry.
Repair of lacerations that require layered closure of one or more of the deeper layered of the skin and tissues is known as:
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:
CC (Chief Complaint)
In dealing with managed care plans, a referral is:
The transfer of the total or specific care of a patient from one physician to another or the term used when requesting an authentication for the patient to receive services elsewhere.
What does comorbidity mean:
Underlying diseases or other conditions present at the time of the visit.
A new patent is one who:
Has not received any professional services from a physician who belongs to a group practice within the past 3 years.
The chronological recording of pertinent facts and observations about the patient's health is known is: