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Records and SOAP Matching
What are the 3 formats of patient records?
Source oriented, problem oriented and combination.
Medical records can be detroyed after how many years of inactivity?
8 years
What is the only color ink acceptable for medical records?
black
What type of paper records is AAHA approved?
letter size folders
How often should records be reviewed for inactivity?
annually
What are the 3 methods of filing medical records?
Alphabetical by last name, numeric by client number and color coded.
What 3 things should always be included with any entry on a medical record?
initial, date and time
What patient record format is AAHA approved?
Problem oriented
What are the only 3 reasons medical records can be released without owners permission?
bite cases, court orders and reportable diseases
What is the most common method for record in regards to "whole herd records"?
carbonized sheets
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