medical records
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When the names of two or more individuals are exactly the same, the first consideration after the name for indexing is.
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State, city, street name, street number, date of birth
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Indicate the third indexing unit for the name Mr. Johnson marc Herman, Jr
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Marc
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What is considered to be subjective
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Information provided by the patient/system
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SOAP stands for
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Subjective, objective, assessment, plan
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To indicate a folder had been removed from the filing cabinet and is in someone's possession, you would use an
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Outguide
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Indexing is a step in filing which
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Decides where to file the letter/ paper
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What is objective information
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Information provided by the physician, ma, or what you see
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The order in which progress notes, laboratory reports. x-ray reports, etc., are added to the patients medical record is
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Chronologically
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All medical records are considered to be the property of the physician, but no one can see a patients medical record without
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Patient consent or authorization
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A diagnosis based sorely on the evaluation of the health history of the patient and physical examination findings is called an
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Clinical diagnosis
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The procedure for filing reports and letters requires several steps. What is the last (final) step in the filing process
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Locate draw itself, place papers with heading to left and most current on top
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When legal action is taken against a physician, medical records can
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Support physician in defense against a claim (subpoena)
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A notation in a file that indicates a certain paper is filed elsewhere is referred to as an
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Cross-reference
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Photocopies of patients information received by fax transmission on thermal paper should always be photocopied before placing in the patients chart because
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Thermal paper fade and can become unreadable
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When errors regarding information are noted in the patients chart, they must be corrected using legally acceptable technique. What is the proper procedure for correcting an error in a medical record
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Draw a single line through info, note recorded in area, initial and date
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A type of file that is set up to remind patients to come in for their regular checkups is commonly referred to as a
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Tickler file
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the process of removing all pins and paper clips from the papers prior to filing is feferred to as
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Conditioning
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The problem-oriented medical record is
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Plan for patient care using SOAP
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Which portion of the medical history is supplied by the patient
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Subjective
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What is the one thing that you should never do when correcting a medical record
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Do not erase
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Where would the most logical place be file an article about HIV infection
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By subject in physcian filing
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Any indication of disease or illness perceived by the patient is referred to as an
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Symptom
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Where would you find a file for henry wilson medical instruments corporation
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The letter H
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the art of distinguishing between two similar diseases by contrasting their symptoms is called
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Differential diagnosis
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What is the fourth indexing unit for this name the martin cole medical instruments company
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Instruments
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One of the most important duties of a medical assistant is to
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Fill out and maintain accuracte and thorough information
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The role the medical assistant plays in patient education is to explain
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the management of the patients condition as outlined by the physcian
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How are patient records are used in medical research
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Patient responeses, behavior, side effects, and outcome
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What of the following information is found on the patien regristration form
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Address
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a summary ocf the reason the patient enetered the hospital, the care the patient received in the hospital, and the outcome is found in the
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Discharge summary form
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The best way to make sure the physcian sees a patients X-ray report before filing it is to
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Have the physcian initial reports
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A physcian tries unsuccessfully to call a patient. The medical assistant should
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Record date of call in patients records
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The O section of soap documentation is
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Data that comes from a physcian
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The A section of soap documentation is
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Diagnosis
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The P section of soap documentation is
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Plan of action include treatment injucation follow up
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when may a physcian release a patients record
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In case of contajous disease or when subpoena by court
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When is it appropriate to send the original document
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Never
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The reason a patients record would no be sent by fax machine is because
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No way to see who will see the document
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When do most states consider children to be adults with the right to privacy
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18
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The first step to updating a patients medical record is to
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Verify you have the right record for the right patient
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A medical record from another physcian should be
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Entered into the patients charts
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Which of the following is a guideline for arranginging files in alphabetical order
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Hypenated names is considered a single unit
