MED 118: CHAPTER 7.AN ULTIMATE A+ QUESTIONS AND
ANSWERS BREAKDOWN
medical records
"what's in the office day to day"
•Collection of data recorded when a patient seeks medical treatment.
•Hospitals, surgical centers, clinics, physician offices, and other facilities providing
health care services maintain patients' medical records.
•Required by licensing authorities to track, document, and maintain patient data.
•Provide documentation of a patient's continuing health care from birth to death.
•Provide a foundation for managing a patient's health care.
•Serve as legal documents in lawsuits.
•Provide clinical data for education, research, statistical tracking, and assessing the
quality of health care.
electronic records
•Electronic medical record (EMR): Digital version of the paper chart in the clinician's
office.
•Electronic health record (EHR): Digital version of the patients' total health information in
one record.
5 C's of Documentation
•Concise.
•Complete (and objective).
, •Clear (and legibly written).
•Correct.
•Chronologically ordered.
subjective
"I feel sick to my stomach"
"subject"
objective
- what you can measure, what you can see
"object"
consent form for patient imaging
•Patient knows that imaging will be used to document care.
•Ownership rights belong to the facility but imaging can be viewed or copied.
•Images will be securely stored for specified time period.
•Images will not be released to outside agency without written authorization.
modifications to medical records
•Correction:
•Addendum:
•Amendment:
correction
Change in information in that is meant to clarify inaccuracies found after the written
document is complete. Draw a line through incorrect information so that it is still legible.
ANSWERS BREAKDOWN
medical records
"what's in the office day to day"
•Collection of data recorded when a patient seeks medical treatment.
•Hospitals, surgical centers, clinics, physician offices, and other facilities providing
health care services maintain patients' medical records.
•Required by licensing authorities to track, document, and maintain patient data.
•Provide documentation of a patient's continuing health care from birth to death.
•Provide a foundation for managing a patient's health care.
•Serve as legal documents in lawsuits.
•Provide clinical data for education, research, statistical tracking, and assessing the
quality of health care.
electronic records
•Electronic medical record (EMR): Digital version of the paper chart in the clinician's
office.
•Electronic health record (EHR): Digital version of the patients' total health information in
one record.
5 C's of Documentation
•Concise.
•Complete (and objective).
, •Clear (and legibly written).
•Correct.
•Chronologically ordered.
subjective
"I feel sick to my stomach"
"subject"
objective
- what you can measure, what you can see
"object"
consent form for patient imaging
•Patient knows that imaging will be used to document care.
•Ownership rights belong to the facility but imaging can be viewed or copied.
•Images will be securely stored for specified time period.
•Images will not be released to outside agency without written authorization.
modifications to medical records
•Correction:
•Addendum:
•Amendment:
correction
Change in information in that is meant to clarify inaccuracies found after the written
document is complete. Draw a line through incorrect information so that it is still legible.
