SOLVED

21. 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 22. 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. 23. 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 24. 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 25. 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 26. 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 27. 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 28. 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. 29. How does a physician document updates to a History and Physical when seeing a patient between annual visits? a.Updates are only done on annual visits. b.By writing a new History and Physical c.By making a note in the History and Physical section of the chart d.By having the patient fill out a questionnaire and placing the questionnaire in the file 30. In which of the following areas of the SOAP note would the diagnosis be found? a.Subjective b.Objective c.Assessment d.Plan