chapter 11

In order to "trust" the information in the medical record, documentation must be ____________ at all times.

accurate

The process of recording information in a patient's medical record is called

documentation

Which of the following documents from other sources frequently become part of a patient's medical record?

All of these

Which of the following is necessary when correcting or making additions to a paper medical record?

All of these and, if possible, a witness should initial entry

Which of the following patient details would be filed under "O" using the SOAP documentation method?

BP 160/92

Which of the 6 Cs means "getting to the point"?

Conciseness

Which filing system uses the patient problem list as the source for filing within the patient medical record?

POMR

Which of the following are possible uses for patient medical records?

Research, quality of care (quality control), and patient education

Which document serves as the "base" for the patient medical record?

The patient medical history form

Why are internal chart audits advisable for every medical office?

To verify that the medical record "backs up" the charges being billed