Chapter 26: The Medical Record Pretest

Which of the following items are NOT part of a patient's demographic information?

• Gender

• Ethnicity

• Religion

• Lab values

• Marital status

The medical record:

• documents patient progress.

• verifies necessity of services to insurance/billing

• serves as a means of communication between providers.

• All of the above

The S in SOAP stands for:

• subjective

• subordinate

• symptomatic

• standard

CHEDDAR is an acronym used for:

• determining which accounting method is used in the practice.

• conducting a patient encounter.

• retrieving patient billing information.

• evaluating laboratory results.

"Meaningful use" refers to:

• how a prescription is taken.

• what type of labs are ordered.

• billing practices.

• the manner in which electronic health records are used.

Advantages of electronic health records include:

• A. eliminating the need for transcription.

• B. decreasing or eliminating errors related to poor or illegible handwriting.

• C. aboloshing the need to secure patient files.

• D. providing a means for patients to diagnose themselves and decrease medical costs.

• A and B only

Regarding storing medical records, which is TRUE?

• Patient records must be stored indefinitely.

• Records must be maintained for 15 years.

• Records may be purged on a regular basis to make room for new charts.

• Records of deceased patients may be destroyed after a death certificate is received.