UPDATED ACTUAL Exam Questions and
CORRECT Answers
how can medical records be organized? - CORRECT ANSWER -chronologically or as
source oriented
or problem-oriented records.
there is no such thing as a progressive type of record organization.
what is POMR? - CORRECT ANSWER -problem oriented medical record is record of
clinical practice that divides medical action in to 4 categories
what are these 4 categories? - CORRECT ANSWER -data base
problem list
treatment plan
progress notes
data base - CORRECT ANSWER -chief complaint,present illness , patient profile, review
of systems, physical examination, and lab reports.
problem list - CORRECT ANSWER -a numeric titled list of every problem that the patient
has that requires management or work up includes social and demographic troubles in addition to
surgical or medical one.
treatment plan - CORRECT ANSWER -includes management additional workups needed
and therapy each plan is titled and numeric with respect to the problem.
the progress note - CORRECT ANSWER -are the part of the medical record where
healthcare professionals record details to document a patient clinical status. it usually follow the
soap approach.
, what is soap? - CORRECT ANSWER -soap is an acronym for:
subjective,objective,assessment or diagnosis, plans.
subjective - CORRECT ANSWER -patient's complaints
objective - CORRECT ANSWER -clinical evidence or observations
what is the chief complaint? - CORRECT ANSWER -the main problem that the pt. is
experiencing
what is an indirect filing system? - CORRECT ANSWER -numeric filing is an indirect
filing system.an indirect filing system uses an intermediary source or reference, such as a file
card, to locate specific files.
filing methods . there are 3 basic filing methods used in healthcare facilities, name them. -
CORRECT ANSWER -alphabetic by name
numeric
subject
who is the legal owner of the medical record? - CORRECT ANSWER -the physician,
agency or facility where a record is created is the legal owner of that record.
what is the continuity of care? - CORRECT ANSWER -is a medical attention that move
smoothly from one provider to another so that the patient receives that most benefits.
type of filing equipment that might be found in medical office. - CORRECT ANSWER -
rotary circular files,
lateral files
compartable and automated files