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Medical Records

MA Review Medical Records

QuestionAnswer
One of the most common methods of medical record documentation is? EMR-POMR-SOAP-ICD-CPT SOAP - The most common methods of documentaion in the medical office is a SOAP = Subjective-Objective-Assessment-Plan
What does Active Medical Record mean? The chart of a patient seen within 2 to 5 years (dependent on practice type)
What is an Audit? Examine medical record files to ensure accuracy, completeness, and sequence of the documents
What is a CHART? Patients Medical Record
A CLOSED MEDICAL RECORD is what? the chart of a patient not expected to return to the practice, such as a patient who is deceased or has moved.
What does CONDITIONING mean? The preparation of the chart for retention; secure all loose documents, and examine the chart for completion and correct filing order of documents.
What is a EHR (Electronic Health Record)? A patients health information maintained in an electronic format, computerized record.
Originally enacted in 1996, this act contains requirements for patient confidentially. What is that ACT HIPPA - Health Insurance Portability and Accountability Act
The chart of a patient not seen at the specific medical office within the past 2 to 5 years. What type of record is this? Inactive Medical Record
The process of assembling, filing, maintaining, retrieving,transferring,protecting, retaining and destroying medical records is called what/ Medical Records Management
Folders that are inserted on file shelf when file is in use; they designate who took it, when, and where it is, is called what? OUTGUIDES
What does POMR stand for and what does it mean? Problem-Oriented Medical Record - The patients problems are numbered and listed on a form (problem list) placed in front of chart
What is REVERSE CHRONOLOGIC ORDER? A format with the MOST RECENT documenation filed on top of the past documentation
What is SOAP documentation? A format for documenting each medical visit using subjective information, obejective information, an assessment, and a plan in that order
What is SOMR? Source-Oriented-Medical Reocrd -
Created by: kimber954
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