Deck 19: Documentation and Medical Records

Question 1

​A good way for health care professionals to increase their efficiency is to gather all the records for patients to be seen that day and prepare the written documentation in advance for procedures to be done during the day

Answer 1

False

Question 2

Source-oriented charting format is a better approach than continuous chronological record format.

Answer 2

False

Question 3

Which of the following is the best definition of charting?​

A) ​Forms a complete chronological health history of a particular patient
B) ​Collection of all documents that are filed together
C) ​Provides legal protection
D) ​Records observations and information about patients

Answer 3

​Records observations and information about patients

Question 4

Which is the correct way to document a patient's statement about symptoms experienced?​

A) ​Write direct quotes and enclose the entry in quotation marks.
B) ​Write the statement in your own words.
C) ​Note the statement in a shortened form, using standard abbreviations.
D) ​List the symptoms, using correct medical terminology.

Question 5

​A medical record refers to the collection of all documents that are filed together and form a complete chronological health history of a particular patient.

Question 6

Medical charting should be done in pencil because mistakes can be more easily and neatly corrected.

Question 7

​Medical documentation refers to notes and documents that health care workers add to the medical record.

Question 8

The physician's orders are the primary tool used to record, communicate, and coordinate the care given to the patient.

Question 9

Which of the following personnel may write progress notes that are included in the patient's official medical record?​

A) ​Only physicians
B) ​Only nurses
C) ​Only physicians and nurses
D) ​Any health care professional who provides a direct service to the patient

Question 10

​Which of the following statements are true about personal health records (PHR)?

A) ​Includes an assessment of body systems
B) ​Computerized information used by health care systems
C) ​Required by law
D) ​Documents created and maintained by the individual

Question 11

Which of the following items would be included in the personal history?​

A) ​Allergies
B) ​Smoking history
C) ​Family tendency for problems
D) ​Use of illegal drugs

Question 12

Which of the following items would be part of the familial history?​

A) ​Assessment of body systems
B) ​Medical problems of relatives
C) ​Frequency of alcohol use
D) ​Past surgeries of patient

Question 13

​How should the health care professional select appropriate abbreviations to use in written documentation?

A) ​Create personal abbreviations that are clear.
B) ​Refer to a standard medical dictionary.
C) ​Use those learned in medical terminology courses.
D) ​Follow facility policies.

Question 14

An example of a chief complaint would be when the health care provider notes an increase in blood pressure that requires treatment.

Question 15

What is one of the purposes of medical documentation?​

A) ​Prevents lawsuits
B) ​Prevents cost overruns
C) ​Communicates directly with the patient
D) ​Helps ensure compliance with regulatory agencies

Question 16

​A coworker calls from home and asks you to sign his name on a patient chart that he forgot to sign after administering a medication.What should you do?

A) ​Sign his name.
B) ​Sign your name.
C) ​Sign both your names.
D) ​Refuse to sign either name.

Question 17

Medical records are legal documents that can be used as legal evidence in court.

Question 18

Incomplete documentation can result in denial of payment to health providers by insurance companies.

Question 19

Which method of organization describes the source-oriented approach to medical recordkeeping?​

A) ​Chronological order
B) ​By health care specialty
C) ​By the type of health problem
D) ​By the body system affected

Question 20

Flow sheets are forms for specialty needs.

Question 21

Match each section of the medical record with the correct sample contents below.​
​Medications and treatments that have been prescribed

A)​Medical history
B)​Physician's orders
C)​Graphics
D)​Progress notes
E)​Diagnostic tests

Question 22

​Match each term with the correct definition below.
All notes added to a patient's medical record​

A)​Medical documentation
B)​Medical record
C)​Charting
D)​Chief complaint
E)​Assessment

Question 23

Match each section of the medical record with the correct sample contents below.​
​Results of X-rays, electrocardiograms (ECG or EKG), and blood tests

A)​Medical history
B)​Physician's orders
C)​Graphics
D)​Progress notes
E)​Diagnostic tests

Question 24

When using the method known as "charting by exception," only _________________________ are noted.

Question 25

Match each section of the medical record with the correct sample contents below.​
​Complete personal, familial, and social information

A)​Medical history
B)​Physician's orders
C)​Graphics
D)​Progress notes
E)​Diagnostic tests

Question 26

Medical documentation that is not ____________________ is useless and may cause legal problems.

Question 27

Every entry on a medical record must include the ____________________ and ____________________ and the ____________________ of the health care professional who made the entry.

Question 28

Discuss the meaning of the phrase "If it isn't documented, it isn't done." Include in your answer a discussion of the possible consequences of incomplete or missing documentation.

Question 29

List at least eight characteristics of good medical documentation.

Question 30

​Match each term with the correct definition below.
​Reason the patient seeks medical care

A)​Medical documentation
B)​Medical record
C)​Charting
D)​Chief complaint
E)​Assessment

Question 31

​Match each term with the correct definition below.
​Opinions of a health care professional about the nature of the patient's problem

A)​Medical documentation
B)​Medical record
C)​Charting
D)​Chief complaint
E)​Assessment

Question 32

List the four components of problem-oriented charting as outlined by the acronym SOAP.

Question 33

​Match each term with the correct definition below.
​Recording observations and information about patients

A)​Medical documentation
B)​Medical record
C)​Charting
D)​Chief complaint
E)​Assessment

Question 34

Match each section of the medical record with the correct sample contents below.​
​Visual format for recording measurements such as blood pressure

A)​Medical history
B)​Physician's orders
C)​Graphics
D)​Progress notes
E)​Diagnostic tests

Question 35

Match each section of the medical record with the correct sample contents below.​
​Chronological record of care administered

A)​Medical history
B)​Physician's orders
C)​Graphics
D)​Progress notes
E)​Diagnostic tests