1
ROP - Test 3 Questions and Answers
(100% Correct Answers) Already
Graded A+
What is the purpose of medical documentation? Ans:
Communication; Assessment; Quality Assurance;
© 2026 Assignment
Reimbursement; Legal Record; Education; Research
What are the advantages of computerized documentation?
Guru01 - Stuvia
Ans: Information is easy to store and retrieve; Nearly
Expert
unlimited file space is available; Electronic records are easy to
backup for added security; Information is easily added or
attached to patient records; Charting is easier to read; Data can
be entered into a computer more quickly than it can be written
How can you ensure that your documentation is safe on your
computer? Ans: Never give a personal password or computer
signature to anyone, including other healthcare professionals;
Do not leave a computer terminal unattended after logging on;
Follow the correct protocol for correcting errors; Allow only
authorized personal to create, change or delete medical
records; Ensure that stored records are backed up regularly;
Do not leave pt information displayed on a monitor within
view of others; Keep a running log of any electronic copies
made of computerized files; Never use email to send protected
health information, unless it has been encrypted; Follow the
health care agency's confidentiality procedures for
documenting sensitive material (i.e. HIV status)
What are the basic documents that can be found in pt's charts?
Ans: Admission sheet; Graphic sheet/Flow sheet; Physician
, 2
orders; Progress notes; Medical Hx and examination sheet;
Reports; Correspondence and miscellaneous
documentation
What kind of pt information would you find on an admissions
sheet? Ans: name, address, phone number, SS#, birthdate,
marital status, gender, race, and employer
name/address/phone number. Also includes insurance
information, including: carrier, policy number, insurance
company's address/phone number, and co-pay/deductible
© 2026 Assignment
What kind of information would you find on a "flow sheet?"
Guru01 - Stuvia
Ans: Contains a hx of the pt's: vital signs and the date they
Expert
were taken
What may the physician include under the "physician's
orders?" Ans: May include orders for meds, treatments, tests
and f/u care.
Who writes in the "progress notes" section? Ans: Progress
notes record each contact a provider has with a pt (in person
and by phone, email or mail)
What kind of "history" would you find in the pt's medical
history? Ans: Pt hx—allergies, immunizations, childhood
diseases, current and past meds, previous illness, surgeries,
hospitalizations, Family hx, Social hx
What kind of information would you find in the "pt
examination?" Ans: Results of physical exam, Current medical
condition
ROP - Test 3 Questions and Answers
(100% Correct Answers) Already
Graded A+
What is the purpose of medical documentation? Ans:
Communication; Assessment; Quality Assurance;
© 2026 Assignment
Reimbursement; Legal Record; Education; Research
What are the advantages of computerized documentation?
Guru01 - Stuvia
Ans: Information is easy to store and retrieve; Nearly
Expert
unlimited file space is available; Electronic records are easy to
backup for added security; Information is easily added or
attached to patient records; Charting is easier to read; Data can
be entered into a computer more quickly than it can be written
How can you ensure that your documentation is safe on your
computer? Ans: Never give a personal password or computer
signature to anyone, including other healthcare professionals;
Do not leave a computer terminal unattended after logging on;
Follow the correct protocol for correcting errors; Allow only
authorized personal to create, change or delete medical
records; Ensure that stored records are backed up regularly;
Do not leave pt information displayed on a monitor within
view of others; Keep a running log of any electronic copies
made of computerized files; Never use email to send protected
health information, unless it has been encrypted; Follow the
health care agency's confidentiality procedures for
documenting sensitive material (i.e. HIV status)
What are the basic documents that can be found in pt's charts?
Ans: Admission sheet; Graphic sheet/Flow sheet; Physician
, 2
orders; Progress notes; Medical Hx and examination sheet;
Reports; Correspondence and miscellaneous
documentation
What kind of pt information would you find on an admissions
sheet? Ans: name, address, phone number, SS#, birthdate,
marital status, gender, race, and employer
name/address/phone number. Also includes insurance
information, including: carrier, policy number, insurance
company's address/phone number, and co-pay/deductible
© 2026 Assignment
What kind of information would you find on a "flow sheet?"
Guru01 - Stuvia
Ans: Contains a hx of the pt's: vital signs and the date they
Expert
were taken
What may the physician include under the "physician's
orders?" Ans: May include orders for meds, treatments, tests
and f/u care.
Who writes in the "progress notes" section? Ans: Progress
notes record each contact a provider has with a pt (in person
and by phone, email or mail)
What kind of "history" would you find in the pt's medical
history? Ans: Pt hx—allergies, immunizations, childhood
diseases, current and past meds, previous illness, surgeries,
hospitalizations, Family hx, Social hx
What kind of information would you find in the "pt
examination?" Ans: Results of physical exam, Current medical
condition
