In each blank, try to type in the
word that is missing. If you've
typed in the correct word, the
blank will turn green.
If your not sure what answer should be entered, press the space bar and the next missing letter will be displayed. When you are all done, you should look back over all your answers and review the ones in red. These ones in red are the ones which you needed help on. Question: One of the most common of medical record documentation is? EMR-POMR-SOAP-ICD-CPTAnswer: SOAP - The most common methods of documentaion in the medical office is a SOAP = -Objective-Assessment-Plan Question: What does Medical Record mean?Answer: The of a patient seen within 2 to 5 years (dependent on practice type) Question: What is an ?Answer: Examine medical record files to ensure accuracy, completeness, and of the documents Question: What is a ?Answer: Medical Record Question: A MEDICAL RECORD is what?Answer: the chart of a patient not expected to to the practice, such as a patient who is deceased or has moved. Question: What does mean?Answer: The preparation of the chart for retention; secure all loose documents, and examine the chart for completion and correct filing of documents. Question: What is a EHR (Electronic Record)?Answer: A health information maintained in an electronic format, computerized record. Question: Originally enacted in 1996, this act contains requirements for patient confidentially. What is that Answer: HIPPA - Health Insurance Portability and Accountability Question: The chart of a patient not seen at the medical office within the past 2 to 5 years. What type of record is this?Answer: Inactive Record Question: The process of assembling, filing, maintaining, retrieving,transferring,protecting, and destroying medical records is called what/Answer: Records Management Question: Folders that are inserted on file shelf when file is in use; they who took it, when, and where it is, is called what?Answer: Question: What does POMR for and what does it mean?Answer: Problem-Oriented Medical Record - The problems are numbered and listed on a form (problem list) placed in front of chart Question: What is REVERSE CHRONOLOGIC ?Answer: A with the MOST RECENT documenation filed on top of the past documentation Question: What is SOAP ?Answer: A format for documenting each medical visit using subjective , obejective information, an assessment, and a plan in that order Question: What is SOMR?Answer: -Oriented-Medical Reocrd - |
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