The patient chart belongs to:
Medical practice
Straighten and tidy the forms before filing
Identify what would be part of maintaining a patient’s medical record:
You don’t look well.
a subjective statement?
HIPAA requires all medical records and related documents to be retained for how many
years?
Six years
In the history, physical, impression, plan (HPIP) system, which is considered the
assessment/diagnosis?
Impression
What equipment and supplies are needed to create medical records?
All correct
When a patient’s paper chart is opened flat, what is typically found on the right side?
Progress Notes
A complete and accurate medical record provides legal protection for
Both patients and physicians
When filing alphabetically, if two names are identical, which order is used for the address?
State, city, street
When recording progress notes, the specific chief complaint should be:
Written using the patient’s own words
In HPIP, which is considered a subjective finding?
History
In regards to filing, ____ is done by marking the index identifier on the paper to be filed:
Coding
What act was signed into law as part of the American Recovery and Reinvestment Act to
promote health information technology?
Health Information Technology for Economic and Clinical Health (HITECH)
When filing records in a new file cabinet, it is recommended that you:
Place files in the bottom drawers first
A HIPAA Security Rule audit includes a review of all but which category?
Drug authorizations
Most filing systems are based directly or indirectly on what arrangement?
Alphabetical
In HPIP, which is considered an objective finding?
Physical exam
The patient’s heart rate is elevated at 120 beats per minute
objective statement?
Identify equipment and supplies needed in order to store paper medical records:
All of the responses are correct
What does the P in SOAP stand for?
Plans for further studies, treatment, or management
When making a correction to the progress note in an electronic medical record, you
should:
Use the edit feature
What does the I in the HPIP method stand for?
Impression
It distributes files evenly over the given spaces
The primary benefit of a numeric filing system is:
What does the ‘P’ stand for in POMR?
Problem