Lesson 4 Medical Records (Practice
review and Quiz test) well answered
Doctor's documentation ___________the charges on a medical bill. - ANS ✔✔substantiates
If something wasn't _________, it didn't happen. - ANS ✔✔Documented
Responses from this enable the provider to give the patient the best possible care. - ANS
✔✔Patient history
Px is the same as objective in the SOAP format, and stands for what ? - ANS ✔✔physical
examination
This includes all those activities and procedures that the medical facility and staff do to ensure
that a patient's medical record is legible,understandable, timely, error free and reproducible. -
ANS ✔✔Good recording practices
Information is recorded here as the treatment plan moves along. - ANS ✔✔progress report
The format and clarity of the medical record must be such that it can be copied, microfilmed or
even scanned electronically for storage. Consequently, handwritten entries must be made in
which color of ink? - ANS ✔✔Black
The examiner's diagnosis based on clinical findings is referred to as this. - ANS ✔✔Assessment
Which part of entries is critical to the accuracy of the health record. - ANS ✔✔Timeliness
, If the health record cannot be deciphered, the doctor might have to _____the entry. - ANS
✔✔Rewrite
Documentation records diagnoses and _______. - ANS ✔✔procedures
This includes a statement indications that the patient has been informed of the etreatment
plan. - ANS ✔✔Consent to treatment
Which is a true statement about medical records? - ANS ✔✔They are legal business records.
Medical records identify the patient.
They justify diagnoses and treatments.
CC stands for chief complaint and is the same as this in the SOAP format.
A. Diagnosis
B. Subjective
C. Prescription
D. Physical examination - ANS ✔✔Subjective
A rewrite should be requested if the illegible part of the record has been documented legibly,
elsewhere, or is clear on the dictation.
A. True
B. False - ANS ✔✔False
This is extremely important in terms of patient care, as well as for legal purposes. - ANS
✔✔Correcting errors.
review and Quiz test) well answered
Doctor's documentation ___________the charges on a medical bill. - ANS ✔✔substantiates
If something wasn't _________, it didn't happen. - ANS ✔✔Documented
Responses from this enable the provider to give the patient the best possible care. - ANS
✔✔Patient history
Px is the same as objective in the SOAP format, and stands for what ? - ANS ✔✔physical
examination
This includes all those activities and procedures that the medical facility and staff do to ensure
that a patient's medical record is legible,understandable, timely, error free and reproducible. -
ANS ✔✔Good recording practices
Information is recorded here as the treatment plan moves along. - ANS ✔✔progress report
The format and clarity of the medical record must be such that it can be copied, microfilmed or
even scanned electronically for storage. Consequently, handwritten entries must be made in
which color of ink? - ANS ✔✔Black
The examiner's diagnosis based on clinical findings is referred to as this. - ANS ✔✔Assessment
Which part of entries is critical to the accuracy of the health record. - ANS ✔✔Timeliness
, If the health record cannot be deciphered, the doctor might have to _____the entry. - ANS
✔✔Rewrite
Documentation records diagnoses and _______. - ANS ✔✔procedures
This includes a statement indications that the patient has been informed of the etreatment
plan. - ANS ✔✔Consent to treatment
Which is a true statement about medical records? - ANS ✔✔They are legal business records.
Medical records identify the patient.
They justify diagnoses and treatments.
CC stands for chief complaint and is the same as this in the SOAP format.
A. Diagnosis
B. Subjective
C. Prescription
D. Physical examination - ANS ✔✔Subjective
A rewrite should be requested if the illegible part of the record has been documented legibly,
elsewhere, or is clear on the dictation.
A. True
B. False - ANS ✔✔False
This is extremely important in terms of patient care, as well as for legal purposes. - ANS
✔✔Correcting errors.
