Week 3 - Chapter 11

Question 1

The A section of SOAP documentation includes:

Accepted Answer

the diagnosis of impression of a patient's problem

Question 2

The P section of SOAP documentation is:

Accepted Answer

the plan of action

Question 3

__ may review medical records to monitor whether the care provided and the fees charged meet accepted standards.

Accepted Answer

The Joint Commission

Question 4

The best way to make sure the licensed practitioner sees a patient's x-ray report before filing it is to:

Accepted Answer

have the practitioner initial the report

Question 5

The S section of SOAP documentation is:

Accepted Answer

data that comes directly from the patient

Question 6

When do most states consider children to be adults with the right to privacy?

Accepted Answer

age 18

Question 7

Patient records are used in medical research:

Accepted Answer

for data regarding patient responses and side effects

Question 8

Subjective or internal conditions felt by the patient are:

Accepted Answer

symptoms

Question 9

In legal terms, medical records regarded as __ may damage a provider position in a lawsuit.

Accepted Answer

convenient

Question 10

A patient's illness and the reason for a visit to the medical office are found in the:

Accepted Answer

medical history

Question 11

The database in a POMR includes:

Accepted Answer

all of the above

Question 12

The most appropriate way to terminate an initial interview with the patient is:

Accepted Answer

"Is there anything else you would like the doctor to know?"

Question 13

Which of the following is appropriate when correcting a medical record?

Accepted Answer

Place a note near the correction stating why it was made

Question 14

__ is an approach to documentation that provides an orderly series of steps for dealing with any medical case.

Accepted Answer

SOAP

Question 15

What color ink is used by some facilities to ensure handwritten records are the original versus a copy?

Accepted Answer

blue

Question 16

The best place to interview a patient is:

Accepted Answer

in a private room

Question 17

In legal terms, medical records are regarded as having been created in __, or at the time of a patient's visit.

Accepted Answer

due course

Question 18

Internal audits are done:

Accepted Answer

by medical staff on random records

Question 19

The purpose of having a patient sign an informed consent form is to ensure that the ___.

Accepted Answer

patient understands the treatment offered and possible outcomes

Question 20

In the CHEDDAR format of documentation, the C section includes:

Accepted Answer

presenting problems

Questions 20