213 ch 11 3

Which of the following organizations reviews patient health records to monitor whether the care provided and the fee charged met accepted standards

• Utilization review organizations
• Health information exchanges
• The joint Commission

• Insurance companies

The type of documentation that provides an orderly series of steps for dealing with any medical case is

• patient records
• clinical guidelines
• treatment plans
• SOAP

When do most states consider children to be adults with the right to privacy

• 16 years old
• 21 years old
• 17 years old
• 18 years old

In the CHEDDAR format of documentation, the C section includes

• Past Medical History
• Chief Complaint
• Current Medications
• presenting problems

All information should be entered in the record at the time of a patient's visit, not days, weeks or months later. This is called

• real-time documentation
• retrospective analysis
• Due course

• delayed documentation

The best way to make sure the licensed practitioner sees a patient's X-ray report before filing it to_

• have the practitioner initial the report

• Implement a review process before filing.
• File the report immediately without review.
• Send the report to the insurance company first.

Subjective or internal conditions felt by the patient are

• Treatment
• Diagnosis
• Symptoms
• Prognosis

The most appropriate way to terminate an initial interview with the patient is_

• "Is there anything else you would like the doctor to know"

• Ask the patient to schedule a follow-up appointment.
• Provide a detailed medical report to the patient.
• Discuss the patient's medical history in depth.

The P section of SOAP documentation is

• the plan of action

• Observation
• Assessment
• Procedure

The S section of SOAP documentation is

• Assessment
• data that comes directly from the patient

• Subjective
• Objective