AHM 185 TEST 3 UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS
Question:
1. one advantage of paper based medical record systems is
Answer:
people feel secure with a piece of hard copy information in hand
Question:
2. a flow sheet
Answer:
can be used to help view continuous problems and comparative values
Question:
3. SOR system
Answer:
documents are arranged according to sections in the
Question:
4. 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
Question:
5. documenters of the medical record are
Answer:
all individuals who provide health services
Question:
6. 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
Question:
7. SOAP stands for
Answer:
Subjective, Objective, Assessment, and Plan
Question:
8. an example of subjective information would be
Answer:
pain
, Question:
9. when an error in paper-based medical records are discovered, the first step is
Answer:
to draw a single line through the incorrect entry
Question:
10. HPI is
Answer:
a chronological description of the development of the patient's present illness
Question:
11. during a comprehensive PE, what order does the physician exam the body
Answer:
starting at the end, working towards the feet
Question:
12. 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
Question:
13. 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
Question:
14. what equipment is necessary to digitize medical records when converting from a paper-based system to
an electronic system?
Answer:
a scanner
Question:
15. the complexity of medical decision making is dependent what three items?
Answer:
paper documents, electronic documents, and graphic images
Question:
16. when selecting a filing system, determine two things to consider
Answer:
security and expansion
Question:
17. in an indirect filing system, you begin to look for a file by
CORRECT ANSWERS
Question:
1. one advantage of paper based medical record systems is
Answer:
people feel secure with a piece of hard copy information in hand
Question:
2. a flow sheet
Answer:
can be used to help view continuous problems and comparative values
Question:
3. SOR system
Answer:
documents are arranged according to sections in the
Question:
4. 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
Question:
5. documenters of the medical record are
Answer:
all individuals who provide health services
Question:
6. 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
Question:
7. SOAP stands for
Answer:
Subjective, Objective, Assessment, and Plan
Question:
8. an example of subjective information would be
Answer:
pain
, Question:
9. when an error in paper-based medical records are discovered, the first step is
Answer:
to draw a single line through the incorrect entry
Question:
10. HPI is
Answer:
a chronological description of the development of the patient's present illness
Question:
11. during a comprehensive PE, what order does the physician exam the body
Answer:
starting at the end, working towards the feet
Question:
12. 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
Question:
13. 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
Question:
14. what equipment is necessary to digitize medical records when converting from a paper-based system to
an electronic system?
Answer:
a scanner
Question:
15. the complexity of medical decision making is dependent what three items?
Answer:
paper documents, electronic documents, and graphic images
Question:
16. when selecting a filing system, determine two things to consider
Answer:
security and expansion
Question:
17. in an indirect filing system, you begin to look for a file by
