Exam 26: The Medical Record,documentation,and Filing

Match each example of information to the part of the medical record in which it would be found. -Breakdown of the drugs currently prescribed to a patient

Match each example of information to the part of the medical record in which it would be found. -Referral form from another physician

Place the steps of filing in the correct order. -Inspect

The ____ is generally the first person to inspect reports.

​In the HPIP (history,physical exam,impression,plan)system of recording medical information,which is considered the assessment/diagnosis?

Match each term with its definition. -Reprints are very often filed with this

How often should the tickler file be checked?

The primary disadvantage of the _____ filing system is that it requires a degree of familiarity of a certain area.

When the patient's paper chart is opened flat,which of the following is typically found on the right side?

Match each term with its definition. -This term once referred only to Roentgen films,but today also includes ultrasounds,angiograms,MRIs,and other types of images

​Match the filing steps for medical records to the description. -​Step Five: locate the file drawer or shelf with appropriate caption;find the folder;…

Match each example of information to the part of the medical record in which it would be found. -Preliminary report of a patient's test results

​Each filing system has pros and cons.Match the filing system to the "pros" description provided. -​Helpful in epidemiology or research or for maintaining business records including insurance

​Match the filing steps for medical records to the description. -​Step One: divide reports into negative/normal and positive/abnormal for provider to read.

When making a correction to the progress note in an electronic medical record,you should:

​What act was signed into law as part of the American Recovery and Reinvestment Act that provides HHS with the authority to establish programs to improve health care quality through the promotion of health information technology?

​Each filing system has pros and cons.Match the filing system to the "pros" description provided. -​Useful for setting up callbacks of patients for follow-up visits at specified intervals

Match each term with its definition. -May offer the advantage of a treatment otherwise unavailable to a patient and additional care that might not have otherwise been provided

​What equipment and supplies are needed to create medical records?

Match each term with its definition. -Required before any information in a patient chart can be released