When is it more appropriate for the physician, rather than another staff member, to make a follow-up call to a patient?
a. The treatment provided was in the emergency room.
b. The treatment had complications.
c. The complications from a treatment were life threatening.
d. The physician never needs to be the one to follow up on patient progress.
(
Q. 2) Why is it important to have a reason for why you are documenting in a medical record?
a. The patient may see what you have written.
b. The medical record is a legal record and can be used in court.
c. The physician may see what you have written.
d. The less written, the less there is to be reviewed.
(
Q. 3) How can a provider protect the practice when a patient appointment is cancelled?
a. Ask about and document the reason for the appointment and the cancellation
b. Document patient cancellations
c. Charge the patient for cancellations
d. Call the patient and ask if he or she is okay
(
Q. 4) What is unacceptable in a medical record?
a. Documenting in blue ink
b. Documenting in red ink
c. Documenting in black ink
d. Documenting in pencil
(
Q. 5) What information should be detailed when documenting in a medical record?
a. All information
b. Referrals to other physicians or services
c. Weight of the patient
d. Patient complaint
(
Q. 6) What part of the chart should be left blank?
a. Margins of any handwritten page
b. The inside and outside cover of the chart
c. The first page of each section of the chart
d. No part
(
Q. 7) Which of the following is NOT a way to correct a medical record?
a. White out the mistake and write the correction over it
b. Draw a straight line through the error
c. Write error above the lined-through error
d. Initial and date the error you have lined through
(
Q. 8) When filing, what section of the chart is most likely where you would file an x-ray report?
a. Reports
b. History and Physical
c. Physician Notes
d. Lab and Radiology
(
Q. 9) When documenting what a patient said in the medical record, use:
a. past tense (e.g., She stated that she was hungry for days).
b. quotation marks (e.g., I was hungry for days).
c. a summary of your idea of what was being said (e.g., I believe the patient was hungry).
d. it is not necessary to document what the patients says.
(
Q. 10) What should be avoided when documenting in a medical record?
a. Spelling out abbreviations
b. Using abbreviations
c. Using approved abbreviations
d. Using a 0 before a period in a report of measurement
Quick Reply
