209 midterm Flashcards
The appropriate way to delete information on a medical record is to
draw a line through the original information so it is still legible
Audits that are done by medical staff before patient billing is submitted are
prospective internal audits
The A section of SOAP documentation includes
the diagnosis of impression of a patient’s problem
Which of the following organizations reviews patient health records to monitor whether the care provided and the fee charged met accepted standards?
The Joint Commission
Subjective
Pain in the groin
Vomiting through the night
Objective
Elevated temp
Rash
Assessment
Hypertension
Plan
Meds prescribed
Test ordered
The first document found in a patient’s financial record is the
patient registration form
Important information about a patient’s medical history and present condition is found in the
patient’s health record
When is it appropriate to send the original documents in a patient’s health record?
when the record is subpoenaed for a court case
A guideline for releasing medical information is to
call the recipient to confirm that all materials were received
In the CHEDDAR format of documentation, the C section includes
presenting problems.
An example of a symptom is
pain
In which section of the CHEDDAR format of documentation can the diagnosis be found?
Assessment
In legal terms, medical records regarded as __________ may damage a provider position in a lawsuit.
convenient
In the problem-oriented medical record (POMR), which of the following includes a record of the patient’s history, information from the initial interview, and any tests?
database
The type of documentation that provides an orderly series of steps for dealing with any medical case is
SOAP
Recording information in the medical record is called
documentation
An example of a sign is
rash
Subjective or internal conditions felt by the patient are
symptoms
