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Medical Records Test

Enter the letter for the matching Answer
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1.
What is SOAP documentation?
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2.
One of the most common methods of medical record documentation is? EMR-POMR-SOAP-ICD-CPT
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3.
What is an Audit?
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4.
A CLOSED MEDICAL RECORD is what?
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5.
What is REVERSE CHRONOLOGIC ORDER?
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6.
What does POMR stand for and what does it mean?
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7.
What is a EHR (Electronic Health Record)?
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8.
The process of assembling, filing, maintaining, retrieving,transferring,protecting, retaining and destroying medical records is called what/
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9.
What does CONDITIONING mean?
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10.
What does Active Medical Record mean?
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11.
Originally enacted in 1996, this act contains requirements for patient confidentially. What is that ACT
A.
A patients health information maintained in an electronic format, computerized record.
B.
SOAP - The most common methods of documentaion in the medical office is a SOAP = Subjective-Objective-Assessment-Plan
C.
A format with the MOST RECENT documenation filed on top of the past documentation
D.
The preparation of the chart for retention; secure all loose documents, and examine the chart for completion and correct filing order of documents.
E.
Medical Records Management
F.
the chart of a patient not expected to return to the practice, such as a patient who is deceased or has moved.
G.
HIPPA - Health Insurance Portability and Accountability Act
H.
Problem-Oriented Medical Record - The patients problems are numbered and listed on a form (problem list) placed in front of chart
I.
A format for documenting each medical visit using subjective information, obejective information, an assessment, and a plan in that order
J.
The chart of a patient seen within 2 to 5 years (dependent on practice type)
K.
Examine medical record files to ensure accuracy, completeness, and sequence of the documents
Type the Answer that corresponds to the displayed Question.
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12.
What is a CHART?
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13.
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?
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14.
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?
Type the Question that corresponds to the displayed Answer.
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15.
Source-Oriented-Medical Reocrd -

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