QUESTIONS AND ANSWERS
The documentation type that contains various types of analyses or examinations
of body substances collected from the patient.
- History and Physical
- Physician Progress Note
- Operative Report
- Laboratory Report
Laboratory Report
This documentation provides an opinion about a patient's condition from a
physician other than the primary care (attending) physician.
- Consultation
- Nurse's Note
- Face Sheet
- Medication Administration Record
Consultation
A review of the medical record to ensure the standards are met and to determine
accuracy of record documentation.
- Retrospective review
- Annual audit
- Quantitative analysis
- Qualitative analysis
Qualitative analysis
In reference to a medical report, the acronym SOAP stands for:
- Subjective, Objective, Assessment and Proposal
- Subjective, Objective, Appraisal and Plan
, - Subjective, Objective, Assessment and Plan
- Suggestive, Objective, Assessment and Plan
Subjective, Objective, Assessment and Plan
Which of the following is a common documentation error?
- Date and location inconsistencies
- Missing physician signatures
- Incorrect patient identification
- All of the above
All of the above
Which of the following is true in regard to the release of protected health
information (ROI)?
- Covered entities must provide access to the PHI requested no later than 45
calendar days from receipt of request
- A covered entity must provide access to PHI in the manner requested by the
individual
- The fee for copying PHI may include costs associated with searching for and
retrieving the PHI
- HIPAA requirements always supercede state laws in regard to how long a
covered entitiy has to provide a copy of PHI
A covered entity must provide access to PHI in the manner requested by the individual
Which of the following is NOT considered a patient demographic?
- Date of birth
- Insurance information
- Telephone number
- Mother's maiden name
Mother's maiden name
The physician who has been assigned to a patient and has assumed primary
responsibility for the treatment and care of the patient: