Question 1

When should you record exam and test results?

Accepted Answer

A)   Every Friday afternoon
B)   Every Monday morning
C)   Every other Friday
D)   Once a month
E)   As soon as they are availableF) B) and C)
G) A) and B)

Question 2

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

Accepted Answer

The answer of The informed ________ form verifies that a...

Question 3

Subjective or internal conditions felt by the patient are ____.

Accepted Answer

A)   signs
B)   symptoms
C)   responses
D)   goals
E)   outcomesF) None of the above
G) D) and E)

Question 4

Kenneth is preparing copies of X-ray and lab results from Mrs. Vendel's chart to be mailed to another physician's office. He tells you that he thinks this is a waste of time, but Mrs. Vendel called and requested that the records be sent to the other physician's office for a second opinion. How should you respond?

Accepted Answer

A)   "If she likes the second opinion, we may lose Mrs. Vendel's business."
B)   "It's a good thing she called in person so that she could authorize the transfer."
C)   "Mrs. Vendel is infamous for wanting second opinions; we do this all the time."
D)   "I'm not busy right now; do you want any help copying the records?"
E)   "Has Mrs. Vendel signed a written consent to have the records transferred?"F) C) and E)
G) A) and E)

Question 5

The section of a patient medical history form that contains the patient's description of the current condition or complaint is called the _________of present illness section.

Accepted Answer

The answer of The section of a patient medical history...

Question 6

The S section of SOAP documentation is ____.

Accepted Answer

A)   data that comes directly from the patient
B)   the diagnosis or impression of a patient's problem
C)   the plan of action
D)   data that comes from the physician or test results
E)   a description of treatment optionsF) A) and B)
G) A) and C)

Question 7

What does the A in SOAP documentation stand for?

Accepted Answer

A)   Action
B)   Alternative
C)   Application
D)   Assessment
E)   AdjustedF) None of the above
G) A) and B)

Question 8

A medical record received from another health provider should be ___.

Accepted Answer

A)   entered into the patient's chart
B)   placed in a file in the medical office
C)   given to the patient to keep
D)   kept in the physician's office for reference
E)   shredded to maintain confidentialityF) A) and C)
G) All of the above

Question 9

When do most states consider children to be adults with the right to privacy?

Accepted Answer

A)   Age 16
B)   Age 18
C)   Age 21
D)   Age 25
E)   When the child has a jobF) C) and E)
G) C) and D)

Question 10

A patient's illness and the reason for a visit to the medical office are found in the ____.

Accepted Answer

A)   informed consent form
B)   patient registration form
C)   records from other healthcare providers
D)   patient test results
E)   patient medical historyF) A) and C)
G) C) and D)

Question 11

The reason a patient's record should not be sent by fax machine is that ____.

Accepted Answer

A)   copies from a fax machine are difficult to read
B)   there is no way to tell who will see the document
C)   it takes too long to fax each page
D)   fax machines are unreliable
E)   the digital transmission from a fax machine can be corruptedF) B) and E)
G) All of the above

Question 12

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

Accepted Answer

A)   Completeness
B)   Clarity
C)   Conciseness
D)   Chronological order
E)   ConfidentialityF) B) and C)
G) C) and E)

Question 13

In the CHEDDAR format of documentation, the C section includes

Accepted Answer

A)   a list of current medications.
B)   consults.
C)   presenting problems.
D)   contributing information.
E)   assessment of the diagnostic process.F) All of the above
G) A) and E)

Question 14

A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the ____.

Accepted Answer

A)   patient medical history
B)   physician examination form
C)   patient registration form
D)   laboratory results
E)   hospital discharge summaryF) B) and C)
G) D) and E)

Question 15

If an employee of the practice records information inappropriately or inaccurately in a patient's health record, legally the ________ and the employee are held responsible.

Accepted Answer

licensed p...

Exam 11: Medical Records and Documentation

What does the A in SOAP documentation stand for?

Correct Answer
verified

When do most states consider children to be adults with the right to privacy?

Correct Answer
verified

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

Correct Answer
verified

Subjective or internal conditions felt by the patient are ____.

Correct Answer
verified

The reason a patient's record should not be sent by fax machine is that ____.

Correct Answer
verified

A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the ____.

Correct Answer
verified

A medical record received from another health provider should be ___.

Correct Answer
verified

A patient's illness and the reason for a visit to the medical office are found in the ____.

Correct Answer
verified

In the CHEDDAR format of documentation, the C section includes

Correct Answer
verified

The S section of SOAP documentation is ____.

Correct Answer
verified

When should you record exam and test results?

Correct Answer
verified

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

Correct Answer
verified

Correct Answer
verified

If an employee of the practice records information inappropriately or inaccurately in a patient's health record, legally the ________ and the employee are held responsible.

Correct Answer
verified
licensed p...
View Answer

The section of a patient medical history form that contains the patient's description of the current condition or complaint is called the _________of present illness section.

Correct Answer
verified

Exam 11: Medical Records and Documentation

What does the A in SOAP documentation stand for?

Correct AnswerverifiedShow Answer

When do most states consider children to be adults with the right to privacy?

Correct AnswerverifiedShow Answer

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

Correct AnswerverifiedShow Answer

Subjective or internal conditions felt by the patient are ____.

Correct AnswerverifiedShow Answer

The reason a patient's record should not be sent by fax machine is that ____.

Correct AnswerverifiedShow Answer

A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the ____.

Correct AnswerverifiedShow Answer

A medical record received from another health provider should be ___.

Correct AnswerverifiedShow Answer

A patient's illness and the reason for a visit to the medical office are found in the ____.

Correct AnswerverifiedShow Answer

In the CHEDDAR format of documentation, the C section includes

Correct AnswerverifiedShow Answer

The S section of SOAP documentation is ____.

Correct AnswerverifiedShow Answer

When should you record exam and test results?

Correct AnswerverifiedShow Answer

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

If an employee of the practice records information inappropriately or inaccurately in a patient's health record, legally the ________ and the employee are held responsible.

Correct Answerverifiedlicensed p...View AnswerShow Answer

The section of a patient medical history form that contains the patient's description of the current condition or complaint is called the _________of present illness section.

Correct AnswerverifiedShow Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
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Correct Answer
verified

Correct Answer
verified

Correct Answer
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Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
licensed p...
View Answer

Correct Answer
verified