Chapter 11
In order to "trust" the information in the medical record, documentation must be_____________ at all times.
accurate
Charts are usually labeled with the patients medical record number, which is
an alphanumeric number assigned to the patient
When should patients be asked to verify their demographic information?
at every encounter
6 C's of charting
client's words clarity completeness conciseness chronological order confidentiality
Which of the 6 Cs means "getting to the point"?
conciseness
The process of recording information is a patients medical record is called
documentation
Immediately and clearly correcting errors in the medical record helps to prevent legal problems for the physician and
ensures proper care for the patient
Another medical assistant is with you when you notice you made an error on Ms. Jasmine's medical record. It would be good to
have her witness the correction and date and initial the patient record
In what area of the patients chart are demographics updated?
profile
The new patient registration form and the copy of the insurance card are
put in financial records
what cannot be released by a medical office
reports from other physicians
Which of the following are possible uses for patient medical records?
research, quality or car(quality control), patient education
A patients history of present illness includes
severity and onset of disease
To return to the patients face sheet from the demographics area in practice fusion, which of the following should be selected?
summary
Which document serves as a "base" for the patient medical record?
the patient medical history form
Why are internal charts audits advisable for every medical office?
to verify that the medical record "backs up" the charge being billed
transforming spoken notes into accurate form is referred to as:
transcription
Information such as smoking status, caffeine and alcohol use, and living arrangements would be updates in which category?
Social History
Which of the following is NOT an advantage of electronic health records, which includes entering the new patient registration information directly into the computer?
Ability of patients to enter their own data and access the entire medical record
Which of the following patient details would be filed under "O" using the SOAP documentation method?
BP 160/90
CHEDDAR
C- Chief Complaint H- History E- Examination D- Details (of problem and complaint) D- Drugs & dosages A- Assessment R- Return visit information, if applicable
What should you do when you add new informations such as a laboratory or radiology report to a patients medical record?
Document the addition of the report and where it can be found
Mr. Quintana is a new patient who was referred to your office by his primary care physician. When he looks through all the papers that you have given him to complete, he starts yelling at you. His doctor has all of his information and he doesn't understand why you can't get it from Dr. Hart. What should you do?
Empathize with him, offer to assist him, and remain calm and professional
In which category of the patients face sheet would the vital signs be updated in Practice Fusion EHR?
Flowsheets
What is the purpose for placing a date on the top edge of the folder used for patient records and for updating the date periodically?
For easy identification of current patient records
Which of the following is a display of professionalism on the part of the front office medical assistant?
Greet the patient, have him sign in, and provides him with registration forms to complete.
Once registration is complete, the patient should receive a copy of which of the following?
HIPPA notice of privacy practices
Ms. Presutti completed the new patient registration form and medical history form. She comes to the desk and says she doesn't understand why she has to sign the Acknowledgment of HIPAA Notice of Privacy Practices form. What do you tell her?
Her signature confirms that she has been given a copy of them
Which of the following documents from other sources frequently become part of a patients medical record?
Hospital operative notes, hospital discharge summaries, lab results from private labs or hospitals, X-rays, CT scan, and MRI results
If new patient registration information is to be entered directly into the computer, where should this be done?
In a private area
The office has received laboratory and X-ray reports for a new patient. After the physician sees the reports how should they be filed?
In the appropriate section of the file
Based on HIPAA regulations, where is the allergy sticker placed on the patient record in some medical practices?
Inside the front cover
Why must the original content be legible when a correction is made in a patients medical record?
It shows no cover-up was intended
Which of the following is necessary when correcting or making additions to a paper medical record?
Make the correction as close as possible to the original entry, note the reason for the correction, sign and date the correction, all of these and, if possible, a witness to initial entry
Mohammad is a 16-year-old male who is new to the practice. He has previously been diagnosed with asthma by his former physician. In which category of his face sheet should his medications be updated?
Medications
examples of demographic information
Name Date of birth Address Ethnicity Social Security Number Telephone Numbers
How should each form placed in the patient record be labeled with the patients identifying information?
On the front and back
Which filing system uses the patient problem list as a source for filing within the patient medical record?
POMR
Mohammad is a 16-year-old male who is new to the practice. He has previously been diagnosed with asthma by his former physician. In which category of his face sheet should this information be added?
Past medical history
Which of the following is a true statement?
Patient registration forms may be completed on a paper copy or into the EHR
Which of the following is NOT a component of registering a new patient?
Taking a patients vital signs.
What is correct: draw a line through the original information; write the correct information on the next page of the medical record giving the date, time, your initials, and the reason for the correction?
The correction is written above, below, or in the margin near the original content
If changes to the medical record are not done correctly, what can be the result?
The physician may have legal problems related to alterations of the record
In addition to your initials, the date of the correction, and the corrected content, what other information should be documented in the medical record?
The reason for correction
Why is it important to label a patient record correctly?
To help avoid filing errors
