AHM 185 test 3
one advantage of paper based medical record systems is - Answer people feel secure
with a piece of hard copy information in hand
a flow sheet - Answer can be used to help view continuous problems and comparative
values
SOR system - Answer documents are arranged according to sections in the
In a patient medical record, data can be - Answer 1. hand entered by the physician, 2.
dictated by the physician, 3. keyed into the system by the physician, 4. entered by the
MA
documenters of the medical record are - Answer all individuals who provide health
services
the difference between an electronic signature and a digital signature is - Answer the
digital signature is a series of letters or numbers that cannot be altered and an
electronic signature is a facsimile of a person's actual signature
SOAP stands for - Answer Subjective, Objective, Assessment, and Plan
an example of subjective information would be - Answer pain
when an error in paper-based medical records are discovered, the first step is - Answer
to draw a single line through the incorrect entry
HPI is - Answer a chronological description of the development of the patient's present
illness
during a comprehensive PE, what order does the physician exam the body - Answer
starting at the end, working towards the feet
a type of internal review where staff look at medical records to verify that good record
keeping is in place and that documentation is valid before billing is submitted is called a
- Answer prospective review
five reasons for keeping medical records - Answer 1. aid in diagnosis and treatment of
patient, 2. to ensure continuity of care, 3. to verify all services were medically
necessary, 4. to substantiate procedure and diagnostic codes 5. to comply with federal
and state laws
what equipment is necessary to digitize medical records when converting from a paper-
based system to an electronic system? - Answer a scanner
one advantage of paper based medical record systems is - Answer people feel secure
with a piece of hard copy information in hand
a flow sheet - Answer can be used to help view continuous problems and comparative
values
SOR system - Answer documents are arranged according to sections in the
In a patient medical record, data can be - Answer 1. hand entered by the physician, 2.
dictated by the physician, 3. keyed into the system by the physician, 4. entered by the
MA
documenters of the medical record are - Answer all individuals who provide health
services
the difference between an electronic signature and a digital signature is - Answer the
digital signature is a series of letters or numbers that cannot be altered and an
electronic signature is a facsimile of a person's actual signature
SOAP stands for - Answer Subjective, Objective, Assessment, and Plan
an example of subjective information would be - Answer pain
when an error in paper-based medical records are discovered, the first step is - Answer
to draw a single line through the incorrect entry
HPI is - Answer a chronological description of the development of the patient's present
illness
during a comprehensive PE, what order does the physician exam the body - Answer
starting at the end, working towards the feet
a type of internal review where staff look at medical records to verify that good record
keeping is in place and that documentation is valid before billing is submitted is called a
- Answer prospective review
five reasons for keeping medical records - Answer 1. aid in diagnosis and treatment of
patient, 2. to ensure continuity of care, 3. to verify all services were medically
necessary, 4. to substantiate procedure and diagnostic codes 5. to comply with federal
and state laws
what equipment is necessary to digitize medical records when converting from a paper-
based system to an electronic system? - Answer a scanner
