Question 1

Internal audits are done

Accepted Answer

A)   by agencies from outside the medical practice.
B)   by the federal government.
C)   by medical staff on random records.
D)   to catch medical errors.
E)   at a patient's request.F) None of the above
G) All of the above

Question 2

You should make a(n) ________ to medical records in a way that does not suggest any intention to deceive, cover up, alter, or add information to conceal a lack of proper medical care.

Accepted Answer

The answer of You should make a(n) ________ to medical...

Question 3

The best way to make sure the physician sees a patient's X-ray report before filing it is to _____.

Accepted Answer

A)   tell the nurse to tell the doctor the results
B)   place the results on the physician's desk
C)   give the report to another physician in the office to give to him
D)   have the physician initial the report
E)   ask the patient to give the report to the physicianF) All of the above
G) D) and E)

Question 4

The purpose of having a patient sign an informed consent form is to ensure that the ____.

Accepted Answer

A)   patient has a legal recourse against the physician
B)   patient understands the treatment offered and the possible outcomes
C)   physician may terminate care at any time
D)   physician does not have to document every visit
E)   physician can delegate the patient's care to the medical assistantF) B) and E)
G) None of the above

Question 5

The medical assistant is responsible to the ________ and the physician for both the medical and administrative procedures performed and the accurate recording of those procedures.

Accepted Answer

patient

Question 6

The appropriate way to delete information on a medical record is to ____.

Accepted Answer

A)   draw a line through the original information so it is still legible
B)   use correction fluid to cover it up
C)   erase the mistaken data
D)   scratch out the incorrect information
E)   retype the entire record, leaving out the information to be deletedF) A) and D)
G) A) and C)

Question 7

Transforming spoken notes into accurate written form is called ____.

Accepted Answer

A)   transformation
B)   dictation
C)   optical character recognition
D)   medical coding
E)   transcriptionF) None of the above
G) B) and D)

Question 8

"The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation.

Accepted Answer

A)   clarity
B)   too much detail
C)   breach of confidentiality
D)   using the client's words
E)   lack of completenessF) B) and D)
G) A) and B)

Question 9

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) B) and D) E

Question 10

Whether the medical practice uses conventional or POMR charts, you can use the ________ approach to documentation.

Accepted Answer

The answer of Whether the medical practice uses conventional or...

Question 11

An example of a patient sign is ____.

Accepted Answer

A)   a rash
B)   pain
C)   nausea
D)   a headache
E)   a tingling sensationF) A) and B)
G) A) and C)

Question 12

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) A) and B) B

Question 13

The P section of SOAP documentation is ____.

Accepted Answer

A)   data provided by the patient
B)   data provided by test results
C)   the diagnosis or impression of the patient's problem
D)   the plan of action
E)   data provided by the physicianF) B) and D)
G) C) and E)

Question 14

Medical records include which of the following information about the patient?

Accepted Answer

A)   Criminal record
B)   Insurance coverage
C)   Family disputes
D)   Job instability
E)   Mortgage paymentF) None of the above
G) A) and B)

Question 15

The diagnosis made by the physician is found in which section of the CHEDDAR format of documentation?

Accepted Answer

A)   Details of problems and complaints
B)   Assessment
C)   Examination
D)   Chief complaint
E)   HistoryF) D) and E)
G) C) and D)

Question 16

Part of creating timely and accurate records is maintaining a(n) ________ tone in your writing.

Accepted Answer

The answer of Part of creating timely and accurate records...

Question 17

In conventional or ________-oriented medical records, patient information is arranged according to who supplied the data.

Accepted Answer

The answer of In conventional or ________-oriented medical records, patient...

Question 18

All medical records are considered the property of the physician; however, the information they contain belong to the patient and are regarded as ________. The patient's written consent is required to release them.

Accepted Answer

The answer of All medical records are considered the property...

Question 19

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) C) and E)

Question 20

Medical records must be written neatly and legibly, contain up-to-date information, and present a(n) _______, professional record of a patient's case.

Accepted Answer

The answer of Medical records must be written neatly and...

Exam 11: Medical Records and Documentation

Internal audits are done

Correct AnswerverifiedShow Answer

You should make a(n) ________ to medical records in a way that does not suggest any intention to deceive, cover up, alter, or add information to conceal a lack of proper medical care.

Correct AnswerverifiedShow Answer

The best way to make sure the physician sees a patient's X-ray report before filing it is to _____.

Correct AnswerverifiedShow Answer

The purpose of having a patient sign an informed consent form is to ensure that the ____.

Correct AnswerverifiedShow Answer

The medical assistant is responsible to the ________ and the physician for both the medical and administrative procedures performed and the accurate recording of those procedures.

Correct Answerverifiedpatient

The appropriate way to delete information on a medical record is to ____.

Correct AnswerverifiedShow Answer

Transforming spoken notes into accurate written form is called ____.

Correct AnswerverifiedShow Answer

"The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of ____ in documentation.

Correct AnswerverifiedShow Answer

When should you record exam and test results?

Correct AnswerverifiedE

Whether the medical practice uses conventional or POMR charts, you can use the ________ approach to documentation.

Correct AnswerverifiedShow Answer

An example of a patient sign is ____.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedB

The P section of SOAP documentation is ____.

Correct AnswerverifiedShow Answer

Medical records include which of the following information about the patient?

Correct AnswerverifiedShow Answer

The diagnosis made by the physician is found in which section of the CHEDDAR format of documentation?

Correct AnswerverifiedShow Answer

Part of creating timely and accurate records is maintaining a(n) ________ tone in your writing.

Correct AnswerverifiedShow Answer

In conventional or ________-oriented medical records, patient information is arranged according to who supplied the data.

Correct AnswerverifiedShow Answer

All medical records are considered the property of the physician; however, the information they contain belong to the patient and are regarded as ________. The patient's written consent is required to release them.

Correct AnswerverifiedShow Answer

The S section of SOAP documentation is ____.

Correct AnswerverifiedShow Answer

Medical records must be written neatly and legibly, contain up-to-date information, and present a(n) _______, professional record of a patient's case.

Correct AnswerverifiedShow Answer

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B

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