©SOPHIABENNET@2024-2025 Thursday, August 22, 2024 10:21 AM
GG MOA 110 chapter 9 Study Guide with Complete Solutions
medical record - Answer✔️✔️-is a hand written or type-written recording of
information that documents facts and events during the administration of
patient care
the principle reasons for maintaining medical records are.. - Answer✔️✔️-1.
to aid in the diagnosis and treatment of a patient
2. to provide written documentation of directed patient care
3. to endure continuity od care
4. to verify that services were medically necessary
5. to assist in the research of disease and injuries so other patients may
benefit from previous care
6. to substantiate procedure and diagnostic code selections for appropriate
reimbursement
7. to comply with federal and state laws
8. to defend the physician in the event of a lawsuit
to digitize medical records is to... - Answer✔️✔️-convert paper documents
into electronic images using a scanner
three basic types of medical record organization systems used by most
physicians offices are... - Answer✔️✔️-problem oriented medical record
1
, ©SOPHIABENNET@2024-2025 Thursday, August 22, 2024 10:21 AM
source oriented record
integrated record
problem oriented medical record - Answer✔️✔️-contains data of the patients
permanent and temporary problems. other lists can include medication,
blood pressure, lab results, and surgeries
source oriented record - Answer✔️✔️-common paper based medical record
management system that arranges documents according to sections
integrated record - Answer✔️✔️-files all documents in chronological order
with out regard to source
four basic ways information can be entered into the medical record -
Answer✔️✔️-1. physician hand-enters data (hand written)
2. physician dictates
3. physician keys data
4. medical assistant enters data
record keeper - Answer✔️✔️-in a small practice this is a duty done by the
administrative medical assistant. in a larger practice, one person is usually
in charge of all medical records
documenters - Answer✔️✔️-are all individuals who provide health care
services. this can include the receptionist, the insurance specialist and the
clinical medical assistant because we document information as well
2
GG MOA 110 chapter 9 Study Guide with Complete Solutions
medical record - Answer✔️✔️-is a hand written or type-written recording of
information that documents facts and events during the administration of
patient care
the principle reasons for maintaining medical records are.. - Answer✔️✔️-1.
to aid in the diagnosis and treatment of a patient
2. to provide written documentation of directed patient care
3. to endure continuity od care
4. to verify that services were medically necessary
5. to assist in the research of disease and injuries so other patients may
benefit from previous care
6. to substantiate procedure and diagnostic code selections for appropriate
reimbursement
7. to comply with federal and state laws
8. to defend the physician in the event of a lawsuit
to digitize medical records is to... - Answer✔️✔️-convert paper documents
into electronic images using a scanner
three basic types of medical record organization systems used by most
physicians offices are... - Answer✔️✔️-problem oriented medical record
1
, ©SOPHIABENNET@2024-2025 Thursday, August 22, 2024 10:21 AM
source oriented record
integrated record
problem oriented medical record - Answer✔️✔️-contains data of the patients
permanent and temporary problems. other lists can include medication,
blood pressure, lab results, and surgeries
source oriented record - Answer✔️✔️-common paper based medical record
management system that arranges documents according to sections
integrated record - Answer✔️✔️-files all documents in chronological order
with out regard to source
four basic ways information can be entered into the medical record -
Answer✔️✔️-1. physician hand-enters data (hand written)
2. physician dictates
3. physician keys data
4. medical assistant enters data
record keeper - Answer✔️✔️-in a small practice this is a duty done by the
administrative medical assistant. in a larger practice, one person is usually
in charge of all medical records
documenters - Answer✔️✔️-are all individuals who provide health care
services. this can include the receptionist, the insurance specialist and the
clinical medical assistant because we document information as well
2
