Practice Exercises (Section 4) Flashcards
What is not an important use of a medical record?
It can be used to train doctors.
These justify diagnoses and treatments, as well as detail the patient’s previous care for future providers.
Medical Records
The format used and kinds of information recorded in each medical record is ____ from one facility to another.
Similar
This is an important resource for legal protection, financial reimbursement, education, quality assurance and medical research.
Medical Records
If services are provided but not documented, reimbursement to the healthcare provider…
Will not occur.
Which is not contained in all dictation?
The nurse’s notes on the diagnosis and procedure.
____ means the patient’s point of view or complaint.
Subjective
__ stands for diagnosis and is the same as assessment in the SOAP format.
Dx
Which is not one of the good recording practices mentioned in this lesson?
Organization
_______ medical records means the use of abbreviations and arrangement of forms in the medical record is consistent with the medical facility’s standards and procedures.
Understandable
