Questions and Answers
What does the 'E' entry in the SOAPER charting method mean?
Reverse chronologic order is where the most recent item is on the top and older items are filed farther back.
True
When documents are added to a patient's paper record, the most recent information should be placed on top.
True
What is the most frequently used follow-up method?
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Which of the following are common types of filing equipment found in a medical office?
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The computer-based record has no disadvantages, whereas the paper-based record has numerous disadvantages.
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The patient owns the medical record.
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What type of electronic record is created, gathered, managed, and consulted only by authorized clinicians and staff in a single healthcare organization?
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Very little statistical information can be gleaned from an EHR system.
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Which of the following is not a method of organizing a medical record?
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Health records offer protection to the provider during legal proceedings if they are accurate and complete.
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Both the source-oriented medical record (SOMR) and problem-oriented medical record (POMR) statements are accurate.
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By legal definition, if it is not documented, then it did not happen.
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A provisional diagnosis is not a final diagnosis and usually is made before test results are received.
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Study Notes
Health Records Study Notes
- "E" in SOAPER charting signifies evaluation or education during patient encounters.
- Reverse chronological order arranges documents with the most recent on top, older items filed further back.
- When adding documents to a patient's paper record, the latest information must be placed on top.
- The most common follow-up method in healthcare is a tickler file, which helps remind staff of necessary actions on specific dates.
- Medical offices commonly use rotary circular files, lateral files, and automated files for filing equipment.
- Both computer-based and paper-based records have advantages and disadvantages; neither is without flaws.
- The creator of the medical record owns it; typically, this is the physician in an office setting.
- An Electronic Medical Record (EMR) compiles health-related information that can be accessed only by authorized personnel in a single healthcare organization.
- Electronic Health Record (EHR) systems can yield a wealth of statistical information for analysis.
- Medical records can be organized in source-oriented, problem-oriented, or chronological methods; "progressively" is not a recognized organization method.
- Accurate and complete health records provide legal protection to healthcare providers during malpractice proceedings.
- Source-Oriented Medical Records (SOMR) categorize content by its source, while Problem-Oriented Medical Records (POMR) focus on individual patient problems and treatment plans.
- The legal principle states: if it is not documented, it did not happen—documentation is crucial.
- Provisional diagnoses are preliminary and are established before receiving test results, serving as a working hypothesis for clinicians.
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Description
Test your knowledge of health records terminology with these flashcards from Chapter 10. Focus on critical concepts like the SOAPER charting method and the organization of health records. Perfect for healthcare students looking to reinforce their understanding.
