| Question | Answer |
| What is a CHART? | Patients Medical Record |
| The process of assembling, filing, maintaining, retrieving,transferring,protecting, retaining and destroying medical records is called what/ | Medical Records Management |
| 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 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 SOAP documentation? | A format for documenting each medical visit using subjective information, obejective information, an assessment, and a plan in that order |
| What is REVERSE CHRONOLOGIC ORDER? | A format with the MOST RECENT documenation filed on top of the past documentation |
| 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 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 SOMR? | Source-Oriented-Medical Reocrd - |
| What is a EHR (Electronic Health Record)? | A patients health information maintained in an electronic format, computerized record. |
| 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 |
| Originally enacted in 1996, this act contains requirements for patient confidentially. What is that ACT | HIPPA - Health Insurance Portability and Accountability Act |
| 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. |
| 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 |
