DXM ESSENTIALS OF DOCUMENTATION
EXAM WITH COMPLETE QUESTIONS
AND ANSWERS { GRADED A+}
what mneumonic do you use for associated symptoms - ✔✔LOCATES- location, other
symptoms, character, alleviating or aggrevating symptoms, timing, environment,
severity
what is medical record - ✔✔clear, concise, and comprehensive written account of a
person's health history
a medical record is both a _____ and _____ document - ✔✔medical and legal
a medical record details the ____, ______, and _______ - ✔✔complaints, evaluations,
and managements
what is included in medical record - ✔✔encounter notes, patient's history, clinical
findings, diagnostic study results, communication records, patient's progress and
medication
what is the purpose of the MR - ✔✔primary method of communication between
members of healthcare team
MR facilitates a _______ of care - ✔✔community
, the MR provides the documentation patients and payers use to - ✔✔verify billed
services
the MR is a legal function that is used to ____________ between patients and health
care providers - ✔✔track events and transactions
if recorded correctly, the MR will support the doctor about the _____ - ✔✔correctness of
treatment
the most important legal function of a MR is to provide __________ and document the
__________ - ✔✔evidence that appropriate care was given and document the patients
response to care
characteristics of a quality MR - ✔✔clear, concise, comphrensive
legible
organized and detailed
provides sufficient evidence from the history, physical exam, and lab findings
MR provides evidence that the - ✔✔appropriate care was given
documentation for each patient encounter should include? - ✔✔CC, relevant history
(HPI, ROS), PE findings, and diagnostic test results, assessement and plan
at the end of a MR make sure there is a _____ and _____ - ✔✔date and legible
signature of provider
always document the patients ____, ______, and _____- - ✔✔progress, response to
and changes in treatment, and revisions in diagnosis
all billing codes should be supported by - ✔✔documentation
EXAM WITH COMPLETE QUESTIONS
AND ANSWERS { GRADED A+}
what mneumonic do you use for associated symptoms - ✔✔LOCATES- location, other
symptoms, character, alleviating or aggrevating symptoms, timing, environment,
severity
what is medical record - ✔✔clear, concise, and comprehensive written account of a
person's health history
a medical record is both a _____ and _____ document - ✔✔medical and legal
a medical record details the ____, ______, and _______ - ✔✔complaints, evaluations,
and managements
what is included in medical record - ✔✔encounter notes, patient's history, clinical
findings, diagnostic study results, communication records, patient's progress and
medication
what is the purpose of the MR - ✔✔primary method of communication between
members of healthcare team
MR facilitates a _______ of care - ✔✔community
, the MR provides the documentation patients and payers use to - ✔✔verify billed
services
the MR is a legal function that is used to ____________ between patients and health
care providers - ✔✔track events and transactions
if recorded correctly, the MR will support the doctor about the _____ - ✔✔correctness of
treatment
the most important legal function of a MR is to provide __________ and document the
__________ - ✔✔evidence that appropriate care was given and document the patients
response to care
characteristics of a quality MR - ✔✔clear, concise, comphrensive
legible
organized and detailed
provides sufficient evidence from the history, physical exam, and lab findings
MR provides evidence that the - ✔✔appropriate care was given
documentation for each patient encounter should include? - ✔✔CC, relevant history
(HPI, ROS), PE findings, and diagnostic test results, assessement and plan
at the end of a MR make sure there is a _____ and _____ - ✔✔date and legible
signature of provider
always document the patients ____, ______, and _____- - ✔✔progress, response to
and changes in treatment, and revisions in diagnosis
all billing codes should be supported by - ✔✔documentation
