Chapter 11 Medical Records and Documentation

After preparing a patient for an examination, what should a medical assistant ask or state before leaving a patient?

"Is there anything else you would like your provider to know?"

Which of the following apply to making corrections on medical forms?

-Add the date and your initials. -Cross out the old information with one line. -Make a note that the information has changed.

Which of the following are true regarding how information should be updated in a patient's medical record?

-Additions may require a third-party witness. -Additions must be dated and initialed. -Additions should be accompanied by a note explaining them

Which of the following items may included on a hospital discharge summary?

-Admitting diagnosis -Date of admission -Date of discharge

What type of information may be recorded in a patient's medical record?

-All procedures -Follow-up care -Phone calls

For which reasons is blue the preferred ink color for written documentation?

-Blue ink is difficult to match. -Blue ink will copy as black.

In which of the following ways can a medical assistant ensure that data are accurate?

-Check that all numbers have been copied accurately. -Check all information carefully. -Verify information if in doubt as to its accuracy.

Which of the following are components of the medical record?

-Current medical care -Medical history -Personal information

Identify the pieces of information a medical assistant may obtain before an examination.

-Current medications -Vital signs -Responses to treatment

Which pieces of information should be documented about telephone calls from a patient?

-Date and time of call -Who initiated the call -Conclusions or results

How can you ensure that a doctor can readily find the most recent information about a patient?

-Document telephone calls by recording the date and time of each call. -Record the information discussed and conclusions or results. -Establish a procedure for retrieving a file quickly in an emergency.

When documenting information from other sources, what can be included?

-Documents from a hospital -Patients' written release requests -Documents from another physician

Which of the following applies to correspondence with or about a patient?

-Each piece should be stamped with the date received. -Each piece should be kept in the patient's medical record.

Identify the information that is contained on a patient's past medical history form.

-Employment information -Illnesses -Family history -Social history -Surgeries

Which of the following are typically detailed in a medical record?

-Evaluation of the patient -Management of the patient -Treatment given to the patient

-CHEDDAR -Objective -Problem Oriented Medical Record -Source Oriented Medical Record

-Format of medical record documentation that breaks information into smaller components -Information that comes from the physician, examinations, and test results -Medical record composed of the database; problem list; educational, diagnostic, and treatment plan; and progress notes -Medical record with patient information arranged according to who supplied the data

Patients have the option to limit which of the following?

-How the office uses their medical information -How much of the information in medical records is shared

Laboratory and other test results may come from which of the following areas?

-Independent laboratories -Hospitals -In office

Which of the following are examples of test results that must be inserted into a patient's medical record?

-Lab tests -X-ray report

Which materials may be used in creating a new patient paper medical record?

-Labels -File folders -Hole punch -Forms

Which of the following may be included in a treatment plan?

-Medications prescribed -Treatment options -Instructions to the patient

In which ways should corrections be made in a medical record?

-Note the date and the reason for the correction. -Draw a single line through the error. -Write corrected information above or below the original entry.

Which of the following may be included on a hospital discharge summary?

-Patient instructions for care after discharge -History of present illness -Surgeries or procedures obtained in the hospital

To ensure a professional attitude and tone, which of the following pieces of information should be recorded in medical records?

-Patient's chief complaint in the patient's own words -Laboratory or test results -Physician's observations

Identify the information given to the patient through an informed consent form.

-Possible outcomes or side effects of treatment -Possible outcome if no treatment -Any alternative treatments and possible risks

Which of the following are components of a Problem-Oriented Medical Record?

-Progress notes -Educational plan -Problem list

Identify the components of a medical history form.

-Social history -Family medical history -Past medical history

When a patient's broken wrist is documented in the same area of the medical record as the documentation of her stomach ulcer, what type of record is being used?

-Source-Oriented Medical Record -Conventional record

In a ______, patient information is arranged according to who supplied the data.

-Source-Oriented Medical Record -conventional record

Which of the following are examples of information that may be added to a patient's record?

-Test results -Observations -Diagnoses

Which statements are considered acceptable in a patient medical record?

-The patient is unsteady. -The patient has a red rash. -The patient is lethargic.

Identify the uses of patient health records for education purposes.

-To educate patients about treatment plans -To educate healthcare staff about medical conditions -To educate patients about their health conditions

Patients have which rights concerning the use of their PHI?

-To request restrictions on PHI -To limit disclosures of PHI

Which of the following are duties performed by the medical assistant?

-Transcribing dictated provider notes -Post laboratory results in the medical record -Document telephone calls

Which of the following help keep handwritten entries neat and easy to read?

-Using blue or black ink -Using a good-quality pen -Making sure handwriting is legible

During an audit, information in a group of patient records is examined for which characteristics?

-accuracy -completeness

Telephone calls from a patient and calls the doctor makes to a patient must be

-time and dated. -initialed. -documented.

Place the steps for creating a paper medical record for a new patient in order, with the first step on top.

1. Create a chart label according to practive policy. 2. Place the chart label on the right edge of the folder 3. Place the date label on the top edge of the folder 4. Punch holes in the appropiate forms for placement in the record 5. Place all forms in the appropriate sections of the patients records.

Place the steps for correcting paper medical records in order, with the first step on top.

1. Draw a single line through the information to be replaced 2. Write corrected information above or below the line or in the margin 3. Place a note near the correction statating the reasonn it was made 4. Enter the date and time and initial the correction 5. If possible, have another staff member witness and initial the correction.

Place the steps for releasing medical information in order, with the first step on top. Instructions

1. Obtain a signed and newly dated realease from the patient. 2. Make photocopies of the requested original material 3. Call the recipient to confirm that all materials have been received.

In most states, children are considered adults when they reach the age of ______.

18

How many Cs are there to charting?

6

If a patient has requested documents from another physician be sent to your office, what must be provided?

A copy of the patient's written authorization of the release

If you are unsure about the names of procedures, medications, findings, or anything else, what should you do?

Ask the healthcare provider for clarification

When should all information be entered in the patient's medical record?

At the time of a patient's visit

Which of the following means to examine and review a group of patient records for completeness and accuracy?

Audit

Which format of medical records documentation breaks the SOAP format into smaller components?

CHEDDAR

Which of the following supplies is NOT needed to make a correction in a paper medical record?

Correction fluid

Which of the following is NOT one of the 6 Cs of charting?

Curtness

Which of the following is the best way to update information in a paper record?

Draw a single line through the information and add a note, the date, and your initials.

What can patient health records be used for?

Educate patients about their own condition and treatment plans

Which of the following is a guideline that should be followed when releasing medical information?

File a signed and dated authorization in the patient's medical record.

When must patients receive a written notice of privacy practices?

First visit

In which section of a history form does the patient describe the history of the condition that is the reason for the visit?

History of present illness

How are test results from sources outside the practice best organized?

In a section of the record designated for results

Advising a patient of the possible outcomes or side effects of the treatment offered is known as what?

Informed consent

What should be done if there is not enough room near the error to make a correction?

Make a notation near the error as to where the correction may be found.

Which of the following is the most precise and clear description?

Patient got out of bed and walked 20 feet without shortness of breath.

In a court of law, who is held responsible if an employee does not chart appropriately or accurately?

Physician

Under respondeat superior, who is held responsible for the actions of the employees of a practice?

Physician

Records that make it easier for a physician to keep track of a patient's progress are called

Problem-Oriented Medical Records.

Where is the diagnosis and treatment plan recorded for every patient?

Progress note

New patients usually complete which of the following forms first?

Registration form

Which approach to documentation provides an orderly series of steps for dealing with any medical case?

SOAP

What does SOAP stand for?

Subjective, objective, assessment, plan

A medical record is also known as a

chart.

In the CHEDDAR format of medical records documentation, the "C" stands for

chief complaint.

To use precise descriptions and accepted medical terminology is called

clarity.

Information corrected or added improperly after a patient's visit can be regarded as "______" and may damage a doctor's position in a lawsuit.

convenient

Specific information required of a population is known as

demographic information.

The process of recording information in a medical record is called

documentation.

Individuals who are under the age of 18 and living on their own or are married, parents, or in the armed services are considered

emancipated minors.

A form that verifies that a patient understands the offered treatment and its possible outcomes or side effects is called a(n)

informed consent form.

Each piece of correspondence received by the office should be

marked or stamped with the date it was received.

In addition to a review of systems, the physician may perform an examination and record results on a

physical examination form.

Part of creating timely and accurate records is maintaining a(n) ______ tone in your writing when recording information.

professional

Test results are usually organized in ______ order in a medical record.

reverse chronological

What contains an inventory of the body obtained through a series of questions?

review of systems

The abbreviation ROS stands for

review of systems.

After receiving a written notice of privacy practices, patients should

sign a form stating they have received the information.

Continuation of a medical record lasts as long as

the patient is under the doctor's care.