MA 111 Lesson 3 Chapter 11 Medical Records and
Documentation questions with verified answers
-CHEDDAR
-Objective
-Problem Oriented Medical Record
-Source Oriented Medical Record Ans✓✓✓ -Format of medical record
documentation that breaks information into smaller components
-Information that comes from the physician, examinations, and test results
-Medical record composed of the database; problem list; educational, diagnostic,
and treatment plan; and progress notes
-Medical record with patient information arranged according to who supplied the
data
A form that verifies that a patient understands the offered treatment and its
possible outcomes or side effects is called a(n) Ans✓✓✓ informed consent form.
A medical record is also known as a Ans✓✓✓ chart.
Advising a patient of the possible outcomes or side effects of the treatment
offered is known as what? Ans✓✓✓ Informed consent
After preparing a patient for an examination, what should a medical assistant ask
or state before leaving a patient? Ans✓✓✓ "Is there anything else you would like
your provider to know?"
, After receiving a written notice of privacy practices, patients should Ans✓✓✓
sign a form stating they have received the information.
Continuation of a medical record lasts as long as Ans✓✓✓ the patient is under
the doctor's care.
During an audit, information in a group of patient records is examined for which
characteristics? Ans✓✓✓ -accuracy
-completeness
Each piece of correspondence received by the office should be Ans✓✓✓ marked
or stamped with the date it was received.
For which reasons is blue the preferred ink color for written documentation?
Ans✓✓✓ -Blue ink is difficult to match.
-Blue ink will copy as black.
How are test results from sources outside the practice best organized? Ans✓✓✓
In a section of the record designated for results
How can you ensure that a doctor can readily find the most recent information
about a patient? Ans✓✓✓ -Document telephone calls by recording the date and
time of each call.
-Record the information discussed and conclusions or results.
-Establish a procedure for retrieving a file quickly in an emergency.
How many Cs are there to charting? Ans✓✓✓ 6
Documentation questions with verified answers
-CHEDDAR
-Objective
-Problem Oriented Medical Record
-Source Oriented Medical Record Ans✓✓✓ -Format of medical record
documentation that breaks information into smaller components
-Information that comes from the physician, examinations, and test results
-Medical record composed of the database; problem list; educational, diagnostic,
and treatment plan; and progress notes
-Medical record with patient information arranged according to who supplied the
data
A form that verifies that a patient understands the offered treatment and its
possible outcomes or side effects is called a(n) Ans✓✓✓ informed consent form.
A medical record is also known as a Ans✓✓✓ chart.
Advising a patient of the possible outcomes or side effects of the treatment
offered is known as what? Ans✓✓✓ Informed consent
After preparing a patient for an examination, what should a medical assistant ask
or state before leaving a patient? Ans✓✓✓ "Is there anything else you would like
your provider to know?"
, After receiving a written notice of privacy practices, patients should Ans✓✓✓
sign a form stating they have received the information.
Continuation of a medical record lasts as long as Ans✓✓✓ the patient is under
the doctor's care.
During an audit, information in a group of patient records is examined for which
characteristics? Ans✓✓✓ -accuracy
-completeness
Each piece of correspondence received by the office should be Ans✓✓✓ marked
or stamped with the date it was received.
For which reasons is blue the preferred ink color for written documentation?
Ans✓✓✓ -Blue ink is difficult to match.
-Blue ink will copy as black.
How are test results from sources outside the practice best organized? Ans✓✓✓
In a section of the record designated for results
How can you ensure that a doctor can readily find the most recent information
about a patient? Ans✓✓✓ -Document telephone calls by recording the date and
time of each call.
-Record the information discussed and conclusions or results.
-Establish a procedure for retrieving a file quickly in an emergency.
How many Cs are there to charting? Ans✓✓✓ 6
