Chapter 13 Medical Records Management

All of the following statements are true with regard to correcting the electronic medical record EXCEPT:

Generally, a correction is made using the "Delete" function.

All of the following are considered possible advantages of the electronic medical record EXCEPT:

it is currently established and understood.

All of the following statements regarding ownership of medical records are true EXCEPT:

The information within the medical record belongs to the healthcare provider.

When is the patient's medical chart prepared?

The patient's chart is prepared on or before the day of the patient's first visit.

__________include documentation such as the medical history, the physical examination, and the follow-up notes.

clinical notes

Guidelines for correcting the medical record include all of the following EXCEPT:

drawing a single line through the error in black ink.

All of the following are types of files cabinets used in medical clinics where manual files are stored EXCEPT:

horizontal

The __________ groups information in categories such as laboratories, examinations, provider notes, and consulting providers.

source-oriented medical record (SOMR)

State statutes have ruled that medical records are the property of _________. The information within the medical record, however, belongs to __________.

those who create them; the patient