Question 1

The patient ________ form contains legal, financial, and demographic information about the patient.

Accepted Answer

The answer of The patient ________ form contains legal, financial,...

Question 2

Patient X-ray and lab tests should be placed in the medical record according to facility policy, but always in reverse ________ order.

Accepted Answer

The answer of Patient X-ray and lab tests should be...

Question 3

Complete, thorough ________ ensures that the physician will have detailed notes about each contact with the patient and about the treatment plan, patient responses and progress, and treatment outcomes.

Accepted Answer

The answer of Complete, thorough ________ ensures that the physician...

Question 4

Kenneth is preparing copies of X-ray and lab results from Mrs. Vendel's chart to be mailed to another physician's office. He tells you that he thinks this is a waste of time, but Mrs. Vendel called and requested that the records be sent to the other physician's office for a second opinion. How should you respond?

Accepted Answer

A)   "If she likes the second opinion, we may lose Mrs. Vendel's business."
B)   "It's a good thing she called in person so that she could authorize the transfer."
C)   "Mrs. Vendel is infamous for wanting second opinions; we do this all the time."
D)   "I'm not busy right now; do you want any help copying the records?"
E)   "Has Mrs. Vendel signed a written consent to have the records transferred?"F) A) and E)
G) None of the above

Question 5

A medical record received from another physician should be ___.

Accepted Answer

A)   entered into the patient's chart
B)   placed in a file in the medical office
C)   given to the patient to keep
D)   kept in the physician's office for reference
E)   shredded to maintain confidentialityF) B) and C)
G) C) and D)

Question 6

In the problem-oriented medical record (POMR) , which of the following includes a record of the patient's history, information from the initial interview, and any tests?

Accepted Answer

A)   Educational, diagnostic, and treatment plan
B)   Progress notes
C)   Database
D)   Problem list
E)   Subjective notesF) A) and B)
G) B) and E)

Question 7

When you are in doubt about who is ________ to give consent to release information, you should ask your supervisor before releasing confidential medical records.

Accepted Answer

The answer of When you are in doubt about who...

Question 8

The primary problem for which a patient comes to see the physician is known as the ________ complaint.

Accepted Answer

The answer of The primary problem for which a patient...

Question 9

When is it appropriate to send the original documents in a patient's chart?

Accepted Answer

A)   When the record is subpoenaed for a court case
B)   When the record is going to another physician
C)   When the patient signs an authorization to release them
D)   When the insurance company specifically requests them
E)   NeverF) B) and D)
G) B) and C)

Question 10

Information in the medical record provides a plan to follow for the ________ of patient care.

Accepted Answer

The answer of Information in the medical record provides a...

Question 11

The ________ summary form generally includes a summary of the reason the patient entered the hospital; tests, procedures, or operations performed in the hospital; medications administered in the hospital; and the disposition or outcome of the case.

Accepted Answer

The answer of The ________ summary form generally includes a...

Question 12

Which of the following is necessary to release a patient's record to the patient's insurance company?

Accepted Answer

A)   Physician's permission
B)   Patient's written consent
C)   Patient's verbal consent
D)   Either the patient's consent or the physician's release
E)   Verification of the insurance companyF) D) and E)
G) A) and C)

Question 13

Important information about a patient's medical history and present condition is found in the ____.

Accepted Answer

A)   patient's chart
B)   problem-oriented medical record system
C)   medical transcription
D)   medical office record book
E)   scheduling or appointment bookF) A) and E)
G) None of the above

Question 14

A(n) ________audit is frequently done by a third party if fraudulent billing is suspected.

Accepted Answer

The answer of A(n) ________audit is frequently done by a...

Question 15

Which of the following information is found on the patient registration form?

Accepted Answer

A)   Patient allergies
B)   Use of alcohol or drugs
C)   Laboratory results from another physician
D)   Name of the person to contact in an emergency
E)   Social and occupational historyF) A) and B)
G) C) and E)

Question 16

Which of the following is appropriate when correcting a medical record?

Accepted Answer

A)   Black out the incorrect information
B)   Place a note near the correction stating why it was made
C)   Type the correct information over the incorrect data
D)   Write the date and your initials at the end of the medical record
E)   Erase the incorrect information and enter the new informationF) C) and D)
G) B) and C)

Question 17

Recording information in the medical record is called ____.

Accepted Answer

A)   transcription
B)   description
C)   dictation
D)   filing
E)   documentationF) C) and D)
G) None of the above

Question 18

The reason a patient's record should not be sent by fax machine is that ____.

Accepted Answer

A)   copies from a fax machine are difficult to read
B)   there is no way to tell who will see the document
C)   it takes too long to fax each page
D)   fax machines are unreliable
E)   the digital transmission from a fax machine can be corruptedF) C) and D)
G) A) and D)

Question 19

A patient's illness and reason for this visit to the physician are found in the ____.

Accepted Answer

A)   informed consent form
B)   patient registration form
C)   records from other healthcare providers
D)   patient test results
E)   patient medical historyF) B) and D)
G) D) and E)

Question 20

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

Accepted Answer

The answer of The informed ________ form verifies that a...

Exam 11: Medical Records and Documentation

Which of the following information is found on the patient registration form?

Correct Answer
verified

The patient ________ form contains legal, financial, and demographic information about the patient.

Correct Answer
verified

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

Correct Answer
verified

A patient's illness and reason for this visit to the physician are found in the ____.

Correct Answer
verified

Important information about a patient's medical history and present condition is found in the ____.

Correct Answer
verified

A(n) ________audit is frequently done by a third party if fraudulent billing is suspected.

Correct Answer
verified

The reason a patient's record should not be sent by fax machine is that ____.

Correct Answer
verified

Patient X-ray and lab tests should be placed in the medical record according to facility policy, but always in reverse ________ order.

Correct Answer
verified

Which of the following is necessary to release a patient's record to the patient's insurance company?

Correct Answer
verified

In the problem-oriented medical record (POMR) , which of the following includes a record of the patient's history, information from the initial interview, and any tests?

Correct Answer
verified

When you are in doubt about who is ________ to give consent to release information, you should ask your supervisor before releasing confidential medical records.

Correct Answer
verified

A medical record received from another physician should be ___.

Correct Answer
verified

Recording information in the medical record is called ____.

Correct Answer
verified

Correct Answer
verified

Which of the following is appropriate when correcting a medical record?

Correct Answer
verified

Information in the medical record provides a plan to follow for the ________ of patient care.

Correct Answer
verified

The ________ summary form generally includes a summary of the reason the patient entered the hospital; tests, procedures, or operations performed in the hospital; medications administered in the hospital; and the disposition or outcome of the case.

Correct Answer
verified

The primary problem for which a patient comes to see the physician is known as the ________ complaint.

Correct Answer
verified

When is it appropriate to send the original documents in a patient's chart?

Correct Answer
verified

Complete, thorough ________ ensures that the physician will have detailed notes about each contact with the patient and about the treatment plan, patient responses and progress, and treatment outcomes.

Correct Answer
verified

Exam 11: Medical Records and Documentation

Which of the following information is found on the patient registration form?

Correct AnswerverifiedShow Answer

The patient ________ form contains legal, financial, and demographic information about the patient.

Correct AnswerverifiedShow Answer

The informed ________ form verifies that a patient understands the treatment offered and the possible outcomes or side effects of treatment.

Correct AnswerverifiedShow Answer

A patient's illness and reason for this visit to the physician are found in the ____.

Correct AnswerverifiedShow Answer

Important information about a patient's medical history and present condition is found in the ____.

Correct AnswerverifiedShow Answer

A(n) ________audit is frequently done by a third party if fraudulent billing is suspected.

Correct AnswerverifiedShow Answer

The reason a patient's record should not be sent by fax machine is that ____.

Correct AnswerverifiedShow Answer

Patient X-ray and lab tests should be placed in the medical record according to facility policy, but always in reverse ________ order.

Correct AnswerverifiedShow Answer

Which of the following is necessary to release a patient's record to the patient's insurance company?

Correct AnswerverifiedShow Answer

In the problem-oriented medical record (POMR) , which of the following includes a record of the patient's history, information from the initial interview, and any tests?

Correct AnswerverifiedShow Answer

When you are in doubt about who is ________ to give consent to release information, you should ask your supervisor before releasing confidential medical records.

Correct AnswerverifiedShow Answer

A medical record received from another physician should be ___.

Correct AnswerverifiedShow Answer

Recording information in the medical record is called ____.

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

Which of the following is appropriate when correcting a medical record?

Correct AnswerverifiedShow Answer

Information in the medical record provides a plan to follow for the ________ of patient care.

Correct AnswerverifiedShow Answer

The ________ summary form generally includes a summary of the reason the patient entered the hospital; tests, procedures, or operations performed in the hospital; medications administered in the hospital; and the disposition or outcome of the case.

Correct AnswerverifiedShow Answer

The primary problem for which a patient comes to see the physician is known as the ________ complaint.

Correct AnswerverifiedShow Answer

When is it appropriate to send the original documents in a patient's chart?

Correct AnswerverifiedShow Answer

Complete, thorough ________ ensures that the physician will have detailed notes about each contact with the patient and about the treatment plan, patient responses and progress, and treatment outcomes.

Correct AnswerverifiedShow Answer

Correct Answer
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