Chapter 11 Medical Records and Documentation EXAM GUIDE |Question and Answer| Graded A+

Chapter 11 Medical Records and Documentation EXAM GUIDE |Question and Answer| Graded A+ Which statements are considered acceptable in a patient medical record? *Ans* -The patient is unsteady. -The patient has a red rash. -The patient is lethargic. Under respondeat superior, who is held responsible for the actions of the employees of a practice? *Ans* Physician -CHEDDAR -Objective -Problem Oriented Medical Record -Source Oriented Medical Record *Ans* -Format of medical record documentation that breaks information into smaller components -Information that comes from the physician, examinations, and test results -Medical record composed of the database; problem list; educational, diagnostic, and treatment plan; and progress notes -Medical record with patient information arranged according to who supplied the data Identify the uses of patient health records for education purposes. *Ans* -To educate patients about treatment plans -To educate healthcare staff about medical conditions -To educate patients about their health conditions Which of the following are components of the medical record? *Ans* -Current medical care -Medical history -Personal information A medical record is also known as a *Ans* chart. Specific information required of a population is known as *Ans* demographic information. The process of recording information in a medical record is called *Ans* documentation. In a court of law, who is held responsible if an employee does not chart appropriately or accurately? *Ans* Physician In which section of a history form does the patient describe the history of the condition that is the reason for the visit? *Ans* History of present illness